[City of Shreveport] Raise the Roof II

Section 1 of 3 in this document

RAISE THE ROOF II

Raise the Roof II is a revitalization program that replaces dilapidated roofs for elderly and or disabled homeowners in the City of Shreveport. The program is used primarily to address an emergency roof repair as a single trade item. The program has the prerequisite that the house must be basically structurally sound and in compliance with minimum property standards. The program will use pre-established HUD regulations and area median income guidelines to determine eligibility.

How long lived at this address:

What year was your house built?

Marital Status

Phone Number

Female Head of Household

Do you own other real estate property?

If “Yes” please list address:

Have you previously received services from the City of Shreveport for home repairs?

Section 2 of 3 in this document

Have you applied for assistance from one of the following resources?

Were you approved for assistance from your Homeowner’s Insurance Company or FEMA?

Do you consider yourself to be Hispanic?

LIST ALL PERSONS LIVING IN HOUSEHOLD:

Enter First Name, Last Name, Relationship, Age, Sex, Social Security #

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SOURCE OF INCOME: WHAT ARE THE SOURCES OF YOUR INCOME?

Enter Family Member, Employer or Income Source, Address of Employer, Telephone Number, Monthly Income, Additional Income & Source

Enter Family Member, Employer or Income Source, Address of Employer, Telephone Number, Monthly Income, Additional Income & Source Remove Field

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CONSENT TO RELEASE INFORMATION

Signing below authorizes the release of information from your records to the City of Shreveport, Department of Community Development’s Neighborhood Revitalization Program. This authorization is made in connection with an application that has been made in order to obtain CDBG funds for home repair.

This release is specific to all organizations including FEMA.

APPLICANT CERTIFICATION

The applicant (whether one or more) certifies that all information in the application and all information furnished in support of this application, is given for the purpose of obtaining a Housing Rehabilitation grant from the City of Shreveport, Department of Community Development’s Neighborhood Revitalization Program, and is true and complete to the best of the applicant's knowledge and belief. The applicant additionally certifies that the applicant is the OWNER AND OCCUPANT of the property to be repaired. The applicant consents to the verification of any of the information contained in this application.

I understand that the release of information does not guarantee that assistance will be provided, but without the information, assistance may not be available.

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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.

PENALTY FOR FALSE OR FRADULENT STATEMENT: U.S.C. Title 18, Section 1001, provides: “Whoever, in any matter within the jurisdiction of any department or agency of the United States, knowingly and willfully falsifies…or makes any false writing or document knowing the same to contain 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.”