COMMUNITY HOUSING IMACT and PRESERVATION PROGRAM (CHIP)
HOME REPAIR/ REHABILITATION APPLICATION

Name * Phone *
Mailing Address *
City * Zip *County *

Address for Assistance *

Household Members

Primary Applicant

SS# Last Name First Name Date of Birth Relationship
* * * * -
Gender Disabled Race Ethnicity Education
* * * * *
Veteran Health Insurance Income
* * *

Household Member 1

SS# Last Name First Name Date of Birth Relationship
Gender Disabled Race Ethnicity Education
Veteran Health Insurance Income

Household Member 2

SS# Last Name First Name Date of Birth Relationship
Gender Disabled Race Ethnicity Education
Veteran Health Insurance Income

Household Member 3

SS# Last Name First Name Date of Birth Relationship
Gender Disabled Race Ethnicity Education
Veteran Health Insurance Income

Household Member 4

SS# Last Name First Name Date of Birth Relationship
Gender Disabled Race Ethnicity Education
Veteran Health Insurance Income

Household Member 5

SS# Last Name First Name Date of Birth Relationship
Gender Disabled Race Ethnicity Education
Veteran Health Insurance Income
Income Sources

Proof of income must be provided with copies of last 4 pay stubs. Include all benefit letters from SS, child support, pension, unemployment, alimony, etc. for all household members age 18 and over.

Primary Applicant Household Member 1
Employer Employer
Address Address
Occupation Occupation
Employment Start Date Employment Start Date
Monthly Salary Monthly Salary
   
Household Member 2 Household Member 3
Employer Employer
Address Address
Occupation Occupation
Employment Start Date Employment Start Date
Monthly Salary Monthly Salary
   
Household Member 4 Household Member 5
Employer Employer
Address Address
Occupation Occupation
Employment Start Date Employment Start Date
Monthly Salary Monthly Salary
Other Income Sources

Be sure to answer ALL questions and dollar amounts:

Do you receive ADC, OWF, TANF or other public/cash assistance?

If yes, what is the monthly amount $ Annual Amount $

Do you receive Unemployment Benefits?
If yes, what is your weekly amount $ Annual Amount $

Do you receive Social Security?
If yes, what is the monthly amount $ Annual Amount $

Do you receive a Pension?
If yes, what is the monthly amount $ Annual Amount $

Do you receive Child Support?
If yes, what is the monthly amount $ Annual Amount $

Do you receive Alimony?
If yes, what is the monthly amount $ Annual Amount

Do you receive Rental Income?
If yes, what is the monthly amount $ Annual Amount $

Do you receive any other income not listed above?
(Interest income is to be listed on the last page of the application).
If yes, Please explain the type of income along with the monthly and annual amounts:

Do you own real estate/property(s) other than your primary residence?
If yes, provide the total dollar equity amount of all property(s) $
Do you live in a single family dwelling, mobile home, or multifamily dwelling?
Do you own, rent or have a land contract?

Monthly Household Expenses
  Type Monthly Amount Paid To
Mortgage/Rent
Second Mortgage
Property Tax
Home Insurance
Gas
Electric
Water/Sewer
Trash Removal
Insurance Information
Amount of Insurance on Home Insurance Agent
Insurance Agent’s Phone No. Address
Mortgage Information
FIRST MORTGAGE SECOND MORTGAGE
Mortgage Lender Mortgage Lender
Original Amount Original Amount
Balance Owed Balance Owed
Monthly Payment Monthly Payment
Areas In Need Of Repair
Electric
Heating
Plumbing
Roof
Walls/Foundation
Windows/Doors
Floors
Other
Assests/Interest Income
Type of Account Bank/ Institution Amount Household member
Checking 1
Checking 2
Checking 3
Savings 1
Savings 2
Savings 3
Certificate of Deposit
Cash Value of a Life
Insurance
IRA
Money Market
Retirement
Other

Have you disposed of more than $1000 in Assets in the past 2- years (24 months)?
(For a list of inclusions and exclusions see the back of this page)

Are you or any other household member(s) related to an employee, agent, consultant, officer, elected official, or an
appointed official of the city/ county in which you are applying for assistance?
If yes, please give their name, title, and employer
Pursuant to 24 CFR 570.489 (h)

I hereby certify that the information provided in this application is true and complete to the best of my
knowledge. I herby give WSOS permission to verify all information contained in this application.