CUMBERLAND COUNTY AFFORDABLE HOUSING TRUST FUND

DOWN PAYMENT/ CLOSING COST ASSISTANCE PROGRAM

PROGRAM APPLICATION CHECK LIST: PLEASE READ ENTIRE PAGE. Your application for assistance will only be considered if documentation for all of the following SEVEN (7) categories is included with this application; the application must be completed in full; and signed by all adult household members. Please return this application to: The Redevelopment Authority of Cumberland County, Attention Housing Programs Manager, 114 North Hanover Street, Suite 104 , Carlisle , PA 17013 . DO NOT REMOVE THIS PAGE FROM THE APPLICATION. PLEASE SEND ONLY COPIES OF YOUR DOCUMENTS.

1. Employment verification forms (pages 6 & 7 of this application) for all adult household members and for all current employment. (You may make additional copies if your household has more than two (2) current employers). Complete and sign only the top section and return the entire form with this application. This office will contact your employer in order for the employer to complete the rest of the form. If your employer uses The Work Number, please provide the employer’s code, your social security number on the form and please sign the form.

2. Copies of documentation of all sources of income coming to all members of the household such as social security, disability, pensions, dividends, child support, alimony, etc.

3. A copy of the most recent income tax return and W2 form for each adult household member.

4. A copy of the most recent pay stub of all employment for all adult household members.

5. A copy of the most recent account statement for all bank accounts (savings, checking, money market) for each adult household member.

6. A copy of the most recent account statement for all assets including stocks and bonds (excluding retirement accounts from which you are not currently receiving income).

7. A mortgage pre-approval letter from a lender.

8. If you have already attended a certified homebuyer’s workshop, please provide a copy of the letter of completion or the certificate with this application. If you have not attended a workshop, please register for one as soon as possible. Call 866-683-5907 x 300 to register for the next class.

9. If you already have an Agreement of Sale, please provide this office with a copy of the Agreement.

EVERY PERSON WHO WILL BE RESIDING IN THE HOUSE MUST BE INCLUDED ON THIS APPLICATION! EVERY ADULT RESIDING IN THE HOUSE MUST PROVIDE INCOME INFORMATION!

1. NAME

FIRST

MIDDLE

LAST

(MAIDEN)

2. TELEPHONE

DAY

EVENING

3. SOCIAL SECURITY NUMBER:

4. DATE OF BIRTH:

5. PRESENT ADDRESS

6. How long at this address?

7. Currently, I:

rent;

live with family or friends;

own my own home.

8. Have you ever been an owner or co-owner of real estate?

If yes, when did ownership cease?

Did you own the real estate with a spouse from a previous marriage?

9. Marital status:

married;

separated;

divorced;

single.

10. Are you a U.S. citizen?

Yes

(If no, you must provide documentation regarding your immigration status with this application)

11. Employer:

Name:

Address:

Your job title:

How long employed?

12. Additional/part time employer:

Name:

Address:

Your job title:

How long employed?

13. List dependents that will live in the household at least 50% of the time:

NAME:

DATE OF BIRTH:

RELATIONSHIP:

ADDITIONAL ADULT LIVING IN THE HOME

1. NAME

FIRST

MIDDLE

LAST

(MAIDEN)

2. TELEPHONE

DAY

EVENING

3. SOCIAL SECURITY NUMBER:

4. DATE OF BIRTH:

5. PRESENT ADDRESS

6. How long at this address?

7. Currently, I:

rent;

live with family or friends;

own my own home.

8. Have you ever been an owner or co-owner of real estate?

If yes, when did ownership cease?

Did you own the real estate with a spouse from a previous marriage?

9. Marital status:

married;

separated;

divorced;

single.

10. Are you a U.S. citizen?

Yes

(If no, you must provide documentation regarding your immigration status with this application)

11. Employer:

Name:

Address:

Your job title:

How long employed?

12. Additional/part time employer:

Name:

Address:

Your job title:

How long employed?

~~~~~ If there are more that two (2) adults living in the household, please make and additional copy of
this pay and complete for that individual. ~~~~~

GROSS INCOME INFORMATION

GROSS MONTHLY INCOME	ADULT (PAGE 1)	ADULT (PAGE 2)
MONTHLY SALARY/WAGES FROM FULL TIME EMPLOYMENT
MONTHLY SALARY/WAGES FROM PART TIME EMPLOYMENT
MONTHLY BONUS
MONTHLY PENSION
MONTHLY SOCIAL SECURITY
MONTHLY ALIMONY RECEIVED
MONTHLY CHILD SUPPORT RECEIVED
MONTHLY DIVIDENDS
MONTHLY INTEREST
OTHER MONTHLY INCOME: (PLEASE SPECIFY)

MONTHLY TOTAL:

YOU MUST LIST ALL OF YOUR ASSETS (Do not leave blank. Fill in zero if no asset exists):

Checking Account (s) Total Balance:		Savings Account(s) Total Balance:	Money Market Account(s) Total Balance:

Stocks and Bonds (non-retirement): Total Balance:	Description:

Copies of most recent statements from all assets, accounts, pay stubs, documentation of all sources of income including but not limited to pensions, SSI, child support, and alimony payments must be provided with this application in order for this application to be considered.

I/We verify that the information provided above is true and correct. I/We understand that false statements herein are made subject to the penalties of 18 Pa CSA 4904 relating to unsworn falsification to authorities.

_______________________________________________________________ __________

Signature date

_____________________________________________________ _________

Signature date

FIRST TIME HOMEBUYER STATUS CERTIFICATION

I/ We hereby certify that I/we am/are first-time homebuyer(s)* or that I/we have not owned a home within the last three years.

______________________________________________ ____________

Applicant's signature date

_______________________________________________ ____________

Co-applicant's signature date

· A first-time homebuyer is defined as someone who has never before owned a home, has owned a mobile home but not the land the mobile home was located on, or someone who has lost their home due to a divorce settlement and has not owned a home since (displaced homemaker).

INFORMATION FOR GOVERNMENT MONITORING PURPOSES

The following information is requested by the Federal Government for certain types of home ownership and housing rehabilitation programs. You are not required to furnish this information, but are encouraged to do so. However, if you choose not to furnish it, under Federal regulations this Authority is required to note race and ethnicity and gender on the basis of visual observation or surname.

Adult #1

Ethnicity: Are you Hispanic or Latino?               £Yes      £ no
Race:                       £ American Indian or Alaskan native
                                £Black/African American
                                £ Asian
                                £ Native Hawaiian/other Pacific Islander
                                £ White
Gender: £ Female                                £ Male
£ I do not wish to furnish this information.

Adult #2

Ethnicity: Are you Hispanic or Latino?               £ Yes     £ no
Race:                       £ American Indian or Alaskan native
                                £ Black/African American
                                £ Asian
                                £ Native Hawaiian/other Pacific Islander
                                £ White
Gender: £ Female                                £ Male
£ I do not wish to furnish this information.

Please list ethnicity, race, and gender of all other household members.

NUMBER OF ADDITIONAL MEMBERS IN HOUSEHOLD:
Please identify each household member by: ethnicity: Hispanic or Latino or NOT Hispanic or Latino; race: (use 1 of 5 categories shown above); and gender.

1.
2.
3.
4.
5.

Opportunities for Persons with Disabilities:

£ I (or a member of my household) have a disability.

EMPLOYMENT VERIFICATION

Applicant must complete the top section only of this verification. Please return this entire form with your application. Please provide the appropriate contact information (payroll dept., human resource dept.) so this office can verify your employment and income. This office will then send it to this contact. If your company uses The Work Number, please provide the employer’s code and your salary key.


Applicant’s Name (please print)		Social Security No.
Applicant’s Address:
Name of Employer:
Address of Employer:
Phone Number of Employer:
Fax Number of Employer:

To Whom It May Concern:

I would like the requested information regarding my wages furnished to the Redevelopment Authority of the County of Cumberland as soon as possible.

Signature of Applicant Date

FOLLOWING INFORMATION IS TO BE COMPLETED BY AN EMPLOYER ONLY

Employment Data	Pay Data
Applicant’s Date of Employment	Base Pay $ __________________ Annual $ ________________ Weekly $ __________________ Other (Specify) $ __________________ Monthly $ ________________ Hourly
Applicant’s Present Position Title: ____________________	Type	Year to Date as of _______________		Past Year
Is continuance of overtime likely? ___yes ___ no Anticipated overtime in the next 12 months _________________	Base Pay	$		$
Is continuance of bonus likely? ___yes ___no Anticipated bonus next 12 months: $________________	Overtime	$		$
Number of hours worked per week ______________	Commissions	$		$
Anticipated increase or decrease in salary in the next year_________________	Bonus	$		$
Signature: Please print name and phone number:			Title of Employer		Date

Thank you for your cooperation in supplying this information. Please return to Attn. Pat Mrkobrad, Housing Programs Manager, Redevelopment Authority of Cumberland County, 114 N. Hanover St., Suite 104 , Carlisle , PA 17013 or by fax: 717-249-4071. Call 717-249-0789 x 136 if you have any questions.

EMPLOYMENT VERIFICATION

Applicant must complete the top section only of this verification. Please return this entire form with your application. Please provide the appropriate contact information (payroll dept., human resource dept.) so this office can verify your employment and income. This office will then send it to this contact. If your company uses The Work Number, please provide the employer’s code and your salary key.


Applicant’s Name (please print)		Social Security No.
Applicant’s Address:
Name of Employer:
Address of Employer:
Phone Number of Employer:
Fax Number of Employer:

To Whom It May Concern:

I would like the requested information regarding my wages furnished to the Redevelopment Authority of the County of Cumberland as soon as possible.

Signature of Applicant Date

FOLLOWING INFORMATION IS TO BE COMPLETED BY AN EMPLOYER ONLY

Employment Data	Pay Data
Applicant’s Date of Employment	Base Pay $ __________________ Annual $ ________________ Weekly $ __________________ Other (Specify) $ __________________ Monthly $ ________________ Hourly
Applicant’s Present Position Title: ____________________	Type	Year to Date as of _______________		Past Year
Is continuance of overtime likely? ___yes ___ no Anticipated overtime in the next 12 months _________________	Base Pay	$		$
Is continuance of bonus likely? ___yes ___no Anticipated bonus next 12 months: $________________	Overtime	$		$
Number of hours worked per week ______________	Commissions	$		$
Anticipated increase or decrease in salary in the next year_________________	Bonus	$		$
Signature: Please print name and phone number:			Title of Employer		Date