QAC Emergency Home Repair & Special Loans Program Application

Applicant Information

Name

Applicant Phone Numbers

Home

Work

Cell

Applicant Email

Applicant Social Security #

Spouse's Name

Spouse's Social Security #

Do you own your home?

YES

How old is your home?

Please upload a copy of the MOST RECENT Deed to the property or title if it is a mobile home.

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If anyone listed on the deed that is deceased, please supply a death certificate.

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If anyone listed on the deed is not living in the home, please supply a lease or deed for his/her current residence.

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Please upload proof of homeowner's insurance and coverage details. (Usually this is just the first page.)

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Is this your Primary Residence?

YES

Are you currently making payments on a mortgage?

YES

If you are currently making payments on a mortgage for the home in need of repair, please upload the most recent copy of you mortgage statement. (Again, this must show the name and physical address of the homeowner and the balance due on the mortgage.)

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If the home is paid for please provide a mortgage release.

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Please upload a copy of your most recent property tax bill or statement. (This document must show the current tax value of the home and property, your name and physical address, recent payments and any balance due on the property.)

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Do you have a reverse mortgage?

YES

Is the home in foreclosure or currently/recently listed for sale?

YES

Do you own other property?

YES

Please list the address' of the other properties you own:

Home Occupants

How many people currently occupy your home?

Please list the following information for EVERYONE currently living in your home, including the applicants. (Include all adults and children, family and others)

Occupant 1

Name

Date of Birth

Relationship to Homeowner

Occupant 2

Name

Date of Birth

Relationship to Homeowner

Occupant 3

Name

Date of Birth

Relationship to Homeowner

Occupant 4

Name

Date of Birth

Relationship to Homeowner

Occupant 5

Name

Date of Birth

Relationship to Homeowner

If you have more than 5 occupants please list the remaining: Name, Date of Birth, and Relationship to Homeowner:

Family Employment & Income

Please list all sources of income for everyone over 18 living in your household. Including the applicants. (include salaries, retirement, disability, social security, alimony, child support, etc.)

Income 1

Name of Income Source

Gross Amount received Monthly

Upload documentation of Income 1 here

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Income 2

Name of Income Source

Gross Amount received Monthly

Upload documentation of Income 2 here

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Income 3

Name of Income Source

Gross Amount received Monthly

Upload documentation of Income 3 here

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Income 4

Name of Income Source

Gross Amount received Monthly

Upload documentation of Income 4 here

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If there are additional sources of income please list them here (Name of Income Source and Gross Amount received Monthly)

Upload any additional income documentation here

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Upload the most recent 3 bank statements of the owners here

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Is anyone in the household self-employed?

YES

Upload 2020 Income Tax Returns

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Upload 2019 Income Tax Returns

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Upload 2018 Income Tax Returns

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Requested Repairs

Please give a detailed description of the repairs you require. Describe the work that needs to be done, reasons the repairs are necessary, and the desired end result.

Description of Repairs Needed

Please feel free to upload pictures here

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If you already have a quote/proposal for the repairs please upload a copy here

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Required Attachments

In order to completely process your application, the following attachments are required. If you did not previously upload these documents in the form, you may send them seperately to dhcs@qac.org.

A copy of the MOST RECENT Deed to the property or title if it is a mobile home. (Anyone listed on the deed that is deseased, please supply a death certificate. Anyone listed on the deed not living in the home, please supply a lease or deed for his or her current residence.)
A copy of your most recent property tax bill or statement. (This document must show the current tax value of the home and property, your name and physical address, recent payments and any balance due on the property.)
A copy of proof of homeowner's insurance and coverage details. (Usually, this is just the first page.)
If you are currently making payments on a mortgage for the home in need of repair, please include the most recent copy of your mortgage statement. (again, this must show the name and physical address of the homeowner and the balance due on the mortgage.) If the home is paid for, please provide a mortgage release.
Proof of income: please include documentation for all income received by all occupants (age 18 or over) of the home in need of repair (paystubs, income tax returns, retirement statements, SS benefit statements, etc.) These documents must include name of the income source, name of the recipient, and the amount received.
Most recent 3 bank statements of the owners.
2020 Income Tax Returns. NOTE: If you are self-employed, please provide your last 3 years of income tax returns.

Understandings and Signature

Please check the boxes to confirm that you have read the following:

By checking the boxes you confirm that you have read each statement and agree.

I understand that by completing this application, I authorize QAC Emergency Home Repair and Special Loans Program to evaluate my need for home repairs. I understand that the evaluation may include personal visits to my home.

I have answered all application questions truthfully.

I understand that if I do not answer truthfully and still participate in this program; I am responsible for taking money from others who actually need and deserve this type of help.

I understand that even if my application is approved, I may not be served by the program due to lack of funding or any other unforeseen circumstance.

I understand that the QAC Emergency Home Repair and Special Loans Program reserves the right to refuse service to anyone.

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.