Pathways to Homeownership Eligibility InformationWere you living in a rental unit that was impacted by the Memorial Day Tornadoes (May 27, 2019)* Yes No Was your (or your co-applicant's) name on the lease for the rental property at that time (May 27, 2019)* Yes No Was the unit the primary residence of the applicant on the date of the disaster (May 27, 2019)* Yes No Was your (or your co-applicant's) name on the accounts for DP&L/AES or Vectren/Centerpoint for the rental property at that time (May 27, 2019)* Yes No Are you currently receiving subsidized housing assistance? (Section 8, Housing Choice Voucher, or any other subsidized housing)* Yes No I acknowledge that this program is based on household income. Eligible households are at or below 120% Area Median Income. Household income will be calculated by program staff.* Yes No Applicant InformationApplicant’s Last Name* Applicant’s First Name/Middle Initial* 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# Months Live in Household How did you learn about the Pathways to Homeownership Program?*Social Services AgencyNewsSocial MediaOtherSources 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?Years at Job Tornado ImpactAddress at time of tornados:* 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 Were there any other names on the lease for the property at this time?* Yes No Are you currently living in the disaster impacted property?* Yes No Please provide a brief explanation on how your household was impacted by the Memorial Day Tornados: I authorize the State, Unit of General Local Government, or Contractor to obtain information about me and my household that is pertinent to determining my eligibility for participation in the program. I acknowledge that: 1. A photocopy of this form is as valid as the original; AND 2. I have the right to review information received using this form; AND 3. I have the right to copy of information provided to the Subrecipient and to request correction of any information I believe to be inaccurate; AND 4. All adult household members will sign this form and cooperate with the Subrecipient in the eligibility verification process. WARNING: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. 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 program approval. Applicant Signature*Co-Applicant Signature* The following documents MUST be submitted before The HomeOwnership Center can evaluate eligibility: Primary Residence (One of the following): Lease in the applicant's name for the appropriate time period Driver's license listing the impacted dwelling address valid at the time of the storm.Voter Registration listing the impacted dwelling address valid at the time of the stormFEMA letter showing payment received for impacted dwelling contents2018 or 2019 tax return listing the impacted dwelling address valid at the time of the storm Occupancy Documents (One of the following): Copy of a utility bill- electric (DP&L/AES) or natural gas bill (Vectren/Centerpoint) in the applicant's name that encompasses service for May 27, 2019. The bill must match a name and address on the program application. See "How to Get a copy of Your Utility Bill" on our website.Other documents may be considered on a case by case basis. 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. Certification of Applicants It is the Division of Emergency Management (NCEM) policy that all information contained in this application will be verified by the Unit of General Local Government (UGLG) Grantee. Please read the following carefully and in acknowledgement of this policy, please sign your name and date where indicated. I certify the following:I certify the following by checking each statement: Select All All the information contained and submitted in support of this application is true and complete to the best of my/our knowledge and belief I/We are aware that any misrepresentation will result in the forfeiture of my/our right to participate in the Tornado Survivor Pathway to Homeownership Program and may result in legal action agains me/us. I/We understand that completion of this application does not guarantee that my/our eligibility for the Tornado Survivor Pathway to HomeOwnership Program I/We certify that I/we were living in the disaster property address I/we provided on our application and that it was my/our primary residence on May 27, 2019 I/We authorize the staff of the County Corp to obtain specific reports, such as credit reports, which said staff deems necessary to perform its functions. I/We understand that information in this application may be shared with funders for the purpose of 3rd Party verification and funding compliance. Equal Opportunity: In accordance with the provisions of the Equal Opportunity Act and the Tornado Survivor Pathway to Homeownership Program (PTHO) policies, there will be no discrimination against an applicant for these benefits on the basis of age, source of income, sex, race, marital status, sexual orientation, national origin, religion or handicap. If you or a member of your household is an individual with a disability, you have the right to request reasonable accommodation for that disability. The PTHO Program Grantees and subcontractors are committed to assuring that each individual has an equal opportunity to the use and enjoyment of the benefits of this program. Confidentiality: In order to process an application, the County Corp may supply and receive information as detailed in the "Consent to Release" clause that you will execute. Information may also be released to comply with the auditing requirements of program funders. With these two exceptions, all personal and identifying information on an application remains fully confidential.