Applicant’s Last Name* Applicant’s First Name/Middle Initial* Applicant’s Social Security Number* Is there a co-applicant?* Yes No Co-Applicant’s Last Name Co-Applicant’s First Name/Middle Initial Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County* Phone*Alternate PhoneEmail* Family Type* Single Parent/Female Single Parent/Male Two-Parent Household Single Person Two Adults/No Children Non-related Adults with children Multigenerational Household Marital Status* Married Not Married Are you a US Citizen or is anyone in your household (including a child under age 18) a US Citizen?* Yes No Gender* Female Male Other Education* 0-8 9-12 (non-grad) HS Grad/GED Post-Secondary (non-grad) Associate/Bachelor's Degree Graduate Degree Are you disabled?* Yes No Military Status* Veteran Active Military N/A How many people are in your household?* List all household members living with you. List yourself first.Last NameFirst Name, Middle InitialRelationship to ApplicantDate of BirthRaceEthnicity How did you learn about the Mortgage Assistance Program?*Friends/FamilyMortgage CompanySocial MediaSocial Services AgencyOtherFirst Mortgage InformationAre you behind on your mortgage payments?* Yes No Are you currently in foreclosure?* Yes No Are you currently in a forbearance agreement?* Yes No When does the forbearance expire? MM slash DD slash YYYY Do you have a second mortgage?* Yes No Second Mortgage InformationAre you behind on your second mortgage payments? Yes No Are you currently in a forbearance agreement? Yes No When does the forbearance expire? MM slash DD slash YYYY Utility InformationAre you currently behind on utilities? If yes, please upload a copy of most recent bill at the end of this application.* Yes No List utilities that are currently behind (ex. DP&L, Vectren, etc.) Household Income and AssetsWork Status (check all that apply) Employed full-time Employed part-time Unemployed (short-term, 6 months or less) Unemployed (long-term, more than 6 months) Unemployed (not in labor force) Furloughed Migrant Seasonal Farm Worker List all employment since October 1, 2020 for the household:*EmployerPositionAddressContact PersonPhone NumberAffected by COVID-19? Sources of Income for the household: Check all that apply for the last 30 days* Employment Self-employment Social Security SSI/SSD Disability Unemployment No income TANF/ADC Pension Child Support Other Please provide details about your income for each source:*Type of IncomeWho receives it?Amount Recieved in the last 30 Days? COVID-19 StatementsCOVID-19 StatementsAssistance Request Related to COVID-19 Pandemic* Loss of Work/Decrease in Available Hours at Work Forced Work Closure Inability to Access or Get to Work Unpaid Wages or Other Unpaid Compensation Ordinarily Received Increase in Childcare Costs Forced to Take Off Work due to School Closure or Childcare Change Self Quarantined at Home under Government or Medical Recommendation Stay at Home or Shelter in Place Order by any level of Government Authority Forced to Take Off Work to Care for a Family Member Personal or Family Experiencing Illness, Disability, or Mental Health Issues Lack of Access or Delayed Access to Healthcare Experience of Food Insecurity, Shortages, or Delayed Benefits Increase in Family Expenses due to Pandemic or Emergency Preparedness Unemployment Insurance Unavailable, Insufficient, or Delayed Emergency Assistance Unavailable, Insufficient, or Delayed Loss of Social, Financial, or Health Safety Net Fear and Concern of Future Economic and Health Insecurity and Instability If I Pay my Mortgage, I will not be able to meet my or my family's basic needs Other A State of Emergency has been declared in the Uniteds States of America and the State of Ohio due to the COVID-19 global pandemic. There is no person in the country that is not affected by COVID-19. I, like thousands of others across the state, am requesting assistance to pay my mortgage and or utilities in part or in full. I, and/or other residents in my home, have experienced the following circumstances due to the Global Pandemic and State of Emergency it has caused.Please provide a brief explanation for the reasons above. If one of the above is not true, please tell us your COVID-19 hardship. I (we) hereby submit this application for the Mortgage Assistance Program. I (we) certify that all of the foregoing information is true and complete to the best of my (our) knowledge, and hereby give my (our) permission to the HomeOwnership Center of Greater Dayton (HOC) to conduct further mortgage and financial investigation, as deemed necessary to determine eligibility. Furthermore, I (we) agree to abide by the eligibility and program requirements set forth in connection with any opportunities that may be offered to me (us) by the HOC pursuant to this application. I (we) understand that false, inaccurate, or incomplete information in the foregoing application shall be considered cause for me (us) to be disqualified from participation in the HOC Mortgage Assistance Program, and I (we) must immediately notify the HomeOwnership Center of any material change in our circumstances prior to receiving assistance. I (we) understand that we are applying for financial assistance for a property that is my (our) primary residence. I (we) represent that the property will not be used for any illegal or restricted purpose. The applicant(s) understand that the program requirements include restrictions that are subject to change and that submittal of an application is not a guarantee of funding assistance. Applicant Signature*Co-Applicant Signature* The following documents MUST be submitted before The HomeOwnership Center can evaluate eligibility: Photo identification of the applicant(s) (i.e. driver’s license) Most recent mortgage statement that shows principal, interest and current amount due + any recent correspondence from your lender on all mortgages on the property Documentation or explanation of COVID-19 related financial hardship Income documentation for all household members (any and all that apply: paystubs for last 30 days, Unemployment Determination Letter, Social Security award letters for current year, Award letters or statements verifying child support, alimony, pension, disability, etc. Social Security card for each household member Please call us if you have questions about the program or required documents: 937-853-1600. Upload the required documents now.* Drop files here or Select files Max. file size: 2 GB. This program is made possible by funding from the Ohio Coronavirus Relief Fund - Home Relief Grant Emergency Services Program through a grant to the Miami Valley Community Action Partnership.