Mortgage Assistance Program Application Applicant’s Last Name*Applicant’s First Name/Middle Initial*Applicant’s Social Security Number*Is there a co-applicant?*YesNoCo-Applicant’s Last NameCo-Applicant’s First Name/Middle InitialAddress* 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* Marital Status*MarriedNot MarriedAre you a US Citizen or is anyone in your household (including a child under age 18) a US Citizen?*YesNoGender*FemaleMaleOtherEducation*0-89-12 (non-grad)HS Grad/GEDPost-Secondary (non-grad)Associate/Bachelor's DegreeGraduate DegreeAre you disabled?*YesNoAre you a veteran?*YesNoHow 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 AsianAmerican IndianAlaska NativeBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOtherHispanicNon-Hispanic How did you learn about the Mortgage Assistance Program?*Friends/FamilyMortgage CompanySocial MediaSocial Services AgencyOtherFirst Mortgage InformationAre you behind on your mortgage payments?*YesNoAre you currently in foreclosure?*YesNoAre you currently in a forbearance agreement?*YesNoWhen does the forbearance expire? Date Format: MM slash DD slash YYYY Mortgage Company*Account Number*Monthly Payment*Amount Currently Due*Do you have a second mortgage?*YesNoSecond Mortgage InformationAre you behind on your second mortgage payments?*YesNoAre you currently in a forbearance agreement?*YesNoWhen does the forbearance expire? Date Format: MM slash DD slash YYYY Mortgage Company*Account Number*Monthly Payment*Amount Currently Due*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? List all bank, credit union, and investment accounts.*InstitutionAccount NumberCurrent Balance Do you own other property?*YesNoPlease provide the address of your other property: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code COVID-19 StatementsPlease indicate if any of the following statements apply to the Applicant:* I have been laid off as a result of COVID-19. I have been furloughed as a result of COVID-19. I have experienced a reduction in salary or hours as a result of COVID-19. I have been terminated as a result of COVID-19. My employment income was not affected as a result of COVID-19 I, or a member of my household, is at high risk for contracting COVID-19. Children in my household are attending school remotely. Fixed income - expenses increased due to COVID-19 (e.g. grocery delivery, increased transportation expenses). If any of these statements are true, please provide the effective date and explain the circumstances:Please indicate if any of the following statements apply to the Co-Applicant: I have been laid off as a result of COVID-19. I have been furloughed as a result of COVID-19. I have experienced a reduction in salary or hours as a result of COVID-19. I have been terminated as a result of COVID-19. My employment income was not affected as a result of COVID-19 I, or a member of my household, is at high risk for contracting COVID-19 Children in my household are attending school remotely Fixed income – expenses increased due to COVID-19 (e.g. grocery delivery, increased transportation expenses) If any of these statements are true, please provide the effective date and explain the circumstances: 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 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.
