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Home My WebLink AboutLead Safe Lansing ApplicationDevelopment Office Housing Program Application Please call 517-483-4040 if you need assistance filling out this form City of Lansing Development Office 316 N. Capitol Ave., Suite D-1 Lansing MI 48933 517-483-4040 Phone 517-483-6036 Fax GENERAL PROGRAM INFORMATION: • Land Contracts are not eligible for participation. • Properties in the flood plain are only eligible for Lead -based paint remediation and repairs to correct life -threatening emergencies. Flood Insurance is required. • Property taxes must be paid current at time of application • Landlords must agree that vacant and unregistered rentals must be registered and occupied within 9 months of completion of work and must submit tenant income documentation to the Development Office for verification. • Mortgage payments must be current for at least one year at time of application, or have an approved work-out plan in place to receive a Housing Rehab Loan. PART 1: OCCUPANT INFORMATION Occupant Name: Total Number Living in household: Occupant Phone Number: Alternate Phone Number: Occupant E-Mail Address: Best time to reach you: Number of: Adults (over 18) Does a pregnant woman live here? Y❑ or N ❑ Number of children under age 18 Is the Head of Household a Female? Y❑ or N ❑ List ages of Children under age 6 that live here full time List ages of Children under age 6 that visit this home regularly Are you using a Section 8 Housing Choice Voucher to pay rent? Y ❑ or N ❑ If yes, is it administered by Lansing Housing Commission? Y ❑or N ❑ Office Use: Priority Level: Updated July 13, 2017 Page 1 PART 2: OCCUPANT DETAIL All occupants, adult and children must be listed and information complete. Include visiting children under age 6 that are regular visitors (for at least six hours a week, ten weeks per year). This program requires that children under age 6 be tested for blood lead poisoning unless you object. Contact your doctor or local health department to schedule testing. NAME RACE DATE IS CHILD MEDICAID HISPANIC CODE MOST OF VISITING? RECIPIENT? OR (see table RECENT BIRTH Y OR N Y OR N LATINO? below) BLOOD LEAD Y OR N LEVEL OF CHILDREN UNDER AGE 6 IF KNOWN Race Code Table: Use the number in front of the ap Dropriate category to complete the chart above. Single Race Categories 1. White 2. Black or African American 3. American Indian or Alaskan Native 4. Asian 5. Native Hawaiian or Pacific Islander Multi -Race Categories 6. American Indian or Alaskan Native and White 7. Asian and White 8. Black or African American and White 9. Amer. Indian/Alaskan Native and Black/African American 10. Other Multi -racial: Attach additional information to the application if you run out of space. AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR CHILDREN UNDER AGE 6 List each child under age 6 residing in the unit Childs Name: Date of Birth: Last First MI Childs Name: Date of Birth: Last First Mil Childs Name: Date of Birth: Last First MI Childs Name: Date of Birth: Last First MII Visiting Y ❑or N❑ Visiting Y ❑ or N ❑ Visiting Y ❑ or N ❑ Visiting Y ❑ or N ❑ I am the legally authorized representative of the patient listed above. I request the release of the protected health information for the patient listed above as follows: Updated July 13, 2017 Page 2 From: Ingham County Health Department 5303 S. Cedar St. Lansing MI 48911 (517)887-5403 To: City of Lansing Development Office 316 N. Capitol Ave., Suite D-2 Lansing MI 48933 (517)483-4040 Fax (517)483-6036 Specific information to be released: Blood Lead Levels From Date: To Date: Purpose of this Release/Disclosure: Blood Lead Levels to be reported to the Department of Housing and Urban Development as part of the Lead Safe Lansing Program. I acknowledge that if the person/entity that receives this information is not a health care provider or health plan covered by Federal privacy regulations, the information may be disclosed by them and no longer protected by the privacy regulations. I acknowledge that I may revoke this Authorization in writing at any time by contacting the disclosing party (ICH or other entity). Revocations will not apply to information that already has been released. I acknowledge that I have read the above, and that I understand the terms and conditions of this Authorization. I understand that the Ingham County Health Department may not require me to sign this Authorization as a condition for treatment, for payment, for enrollment, or for eligibility for benefits. Authorization for Occupying Child(ren): This Authorization expires on: or six (6) months after the date signed below if left blank Specify Expiration Date Name of person responsible for children residing in the unit (printed): Relationship to patient: ❑ Parent ❑ Legal Guardian ❑ Other (proof of legal authority may be required). ❑ I decline to release information Signature: Authorization for Visiting Child(ren) Name of person responsible for children visiting the unit (printed): Relationship to patient: ❑ Parent ❑ Legal Guardian ❑ Other (proof of legal authority may be required) ❑ I decline to release information Signature: Note: Attach additional pages if necessary. Updated July 13, 2017 Page 3 PART 3: PROPERTY INFORMATION Property Address: City: Zip Code: County: Apartment #: How many apartments in the building: ❑ Owner Occupied ❑ Rental Property How did you hear about this program: Has this property ever been enrolled in a lead program? If yes, which one? PART 4: OWNER INFORMATION (complete only if different from occupant information! Name: El Individual ❑LLC ❑Partnership ❑Corporation Address: Telephone Number: City: State: Zip: Alternate Phone Number: Owner E-Mail Address: Best time to reach you: Are you currently undergoing Bankruptcy? Y ❑ or N ❑ Check all that apply: ❑ Single ❑ Married ❑ Separated ❑ Divorced PART 5: PROGRAM QUESTIONS Please answer all of the questions by checking Yes, Yes No Don't Office Use No or Don't Know. Know Only Was the house built before 1978? Are property taxes paid up through last billing cycle? Is this rental unit registered with Code Enforcement? Is there homeowners insurance to cover theft and fire? Do you agree to have your child tested for lead poisoning? Are the mortgage payments up-to-date? Is this house being purchased on a Land Contract? How long has the occupant lived at this address? Years Months How much is your rent? $ per month What utilities are included in your rent? Check Electric ❑ Water ❑ included utilities. Gas Heat ❑ Gas Water Heater ❑ Electric Heat ❑ Electric Water Heater ❑ Updated July 13, 2017 Page 4 PART 5: INCOME AND ASSETS CHECKLISTS AND DOCUMENTATION REQUIRED This section must be filled out by the Occupant of the property and income documentation must be attached for the OCCUPANT(s) only. Please check the appropriate boxes if anyone age 18 or older receives any of the following income: PLEASE INCLUDE DOCUMENTATION TO SUPPORT ANY INCOME CHECKED BELOW. FOR PAYROLL, PLEASE ATTACH A COPY OF ONE MONTH OF CURRENT PAY STUBS OR THE PREVIOUS YEARS W2. FOR ALL OTHER SOURCES OF INCOME RECEIVED, PLEASE ATTACH A COPY OF THE PAYMENT STATEMENT OR AWARD LETTER. All sources of income checked Y must have documentation submitted. INCOME SOURCE TYPE RECEIVING? NAME OF PERSON(S) GROSS Docu- Y OR N RECEIVING MONTHLY mentation THIS INCOME AMOUNT Included RECEIVED Y or N EMPLOYMENT PAYROLL SELF EMPLOYED PAYROLL UNEMPLOYMENT COMPENSTATION DISABILITY COMPENSATION WORKERS COMPENSATION CHILD SUPPORT ALIMONY SEVERANCE PAY DHS CASH ASSISTANCE SUPPLEMENTAL SECURITY INCOME (SSI) ANNUITY OR RETIREMENT PENSION SOCIAL SECURITY OTHER: Attach additional information if you run out of space. Additional required documentation: ❑ Copy of Current Mortgage Statement (if mortgaged) ❑ Copy of recorded deed proving ownership ❑ Copy of Homeowners Insurance Declaration Page(s) ❑ Copy of current Bank Statements from all household members for all accounts ❑ Copy of Driver License or State of Michigan Identification card for all adults over 18 in household ❑ Copy of Social Security Cards for all adults over 18 in household ❑ Copy of the current lease for each rental unit applying for the program. Updated July 13, 2017 Page 5 PLEASE INCLUDE DOCUMENTATION TO SUPPORT ANY ASSET LISTED BELOW. DOCUMENTATION INCLUDES A CURRENT STATEMENT. All assets checked Y must have documentation submitted. FAMILY PERSON(S) WHO DOCUMENTATION ASSET TYPE ASSETS ASSET BELONGS TO VALUE INCLUDED YorN Yor N Savings Account(s) Checking Account(s) Trusts Rental Property Capital Investments Stocks Bonds Treasury Bills Certificates of Deposit Mutual Funds or Money Market Accounts IRA's 401(K) Keogh Accounts Retirement Fund Life Insurance Policies available before death (i.e. surrender value of whole life or universal life policy) Personal Property held as investment Lump Sum or one-time receipts (inheritance, capital gains, lottery winnings, insurance settlements, victims restitution Mortgages or Deeds of Trust held by applicant NOTE: The Development Office reserves the right to request additional documentation to verify the information provided. If additional documentation is needed, you will be contacted. Updated July 13, 2017 Page 6 Rental Projects- Need To Know 1. Remediated units must be rented within 9 months of project completion. Failure to have units rented to eligible tenants within 9 months of project completion is considered a default of the terms/conditions of said documents. The city retains the right under this default condition to declare the entire indebtedness immediately due and payable. 2. Lease agreements cannot contain any of the following: • Agreement to be sued. Agreement by the tenant to be sued, to admit guilt, or to a judgment in favor of the owner in a lawsuit brought in connection with the lease; • Treatment of property. Agreement by the tenant that the owner may take, hold, or sell personal property of household members without notice to the tenant and a court decision on the rights of the parties. This prohibition; however, does not apply to an agreement by the tenant concerning disposition of personal property remaining in the housing unit after the tenant has moved out of the unit. The owner may dispose of this personal property in accordance with state law; • Excusing owner from responsibility. Agreement by the tenant not to hold the owner or the owner's agents legally responsible for any action or failure to act, whether intentional or negligent; • Waiver of notice. Agreement of the tenant that the owner may institute a lawsuit without notice to the tenant; • Waiver of legal proceedings. Agreement by the tenant that the owner may evict the tenant or household members without instituting a civil court proceeding in which, the tenant has the opportunity to present a defense, or before a court decision on the rights of the parties; • Waiver of a jury trial. Agreement by the tenant to waive any rights to a trial by jury; • Waiver of right to appeal court decision. Agreement by the tenant to waive the tenant's right to appeal, or to otherwise challenge in court, a court decision in connection with the lease; and • Tenant chargeable with cost of legal actions regardless of outcome. Agreement by the tenant to pay attorneys' fees or other legal costs even if the tenant wins in a court proceeding by the owner against the tenant. The tenant; however, may be obligated to pay costs if the tenant loses. 3. Termination of Tenancy. Owner may not terminate tenancy, or refuse to renew a lease of rental units assisted with LSL Rental funds except for; • Serious or repeated violation of the terms and conditions of the lease; • Violation of applicable federal, state, or local law; for completion of the transitional housing tenancy period; • Or other good cause. Any termination or refusal to renew must be preceded by not less than 30 days written notice specifying the grounds for the action by the owner's service to the tenant. 4. Maintenance & Replacement. An owner of rental housing assisted with LSL funds must maintain the premises in compliance with all applicable Section 8 housing quality standards and local requirements and standards. I am aware of, and will comply with stipulations outlined in this document. Owner Signature Date Updated July 13, 2017 Page 7 Tenant Displacement Need To Know • You may not displace tenants as a direct result of remediation. This includes the displacement of tenants prior to application into the City of Lansing Development Office's LSL Programs. • Uniform Relocation Requirements are triggered at the time the application is submitted, when the Loan Commitment is executed, and when the remediation is completed. • A displaced person is any person (family, individual, business, farm, or non-profit organization) that moves from the real property, permanently, because of remediation, rehabilitation, demolition, or acquisition for a project with federal funds. • Only a permanently displaced person is eligible for moving, and related expenses. • The City of Lansing Development Office's LSL Program does not allow for the unlawful displacement of tenants. I have read and understand the information provided above. Owner Signature Date Uniform Relocation Act General Information Notice • This is to inform you that if this application is approved, you will not be displaced by lead -based paint relocation, but may be required to move temporarily while certain work is being done. We will keep you informed of the status of the rehabilitation application. We urge you not to move anywhere at this time. • When work on the building is complete, you will be able to lease and occupy your present apartment at an affordable rent. You will be offered a standard lease at that time. • If you must move temporarily while work is underway on the unit or building, suitable temporary housing will be made available to you for that period. • Again, we urge you not to move. If the application for assistance is approved, you can be sure that we will make all efforts to accommodate your needs. Because federal funds would be involved, you would be protected by the Uniform Relocation Act. • If you have any questions about temporary relocation, please call Barbara Kimmel at 517-483- 4053. Tenant Signature Date Updated July 13, 2017 Page 8 CLUTTER NOTICE: ATTENTION OCCUPANTS • A complete inspection of your home will need to be done in order to determine what work needs to be completed to bring your home up to current code. • We will need access to all rooms of your home, including attic and basement spaces, and exterior buildings. • Your home must be free from debris and clutter, and kept in a sanitary condition during the time you are participating in our program. • Failure to comply can result in the project being dropped immediately. • I/we have read and understand this Clutter Notice. Owner Signature Date By signing below, I verify that the answers provided above are accurate to the best of my knowledge. Penalty for false or fraudulent statements: U.S.C. title 18, sec. 1001, provides: "Whoever, in any manner within the jurisdiction of any department or agency of the United States knowingly falsifies, or makes, or uses any false writing or document containing any false, fictitious or fraudulent statement or entry shall be fined not more than $10,000 or imprisoned not more than five years, or both". Tenant Name/Date Tenant Signature Owner Name/Date Owner Signature NOTE: Failure to submit required documentation requested within this application may be cause for program denial. Make certain that you have attached all required documentation prior to submission. ✓ Income documentation is required for all sources of income listed for all household members in the income chart on Page 5. ✓ Additional required documentation listed on the checklist on page 5 is required for processing this application. EQUAL HOUSING OPPORTUNITY Updated July 13, 2017 Page 9