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LEVY COUNTY HHRP-IDALIA APPLICATION FORM

355 Garner Street- Building 1804 Bronson, FL 32621

Email: LevyCountyGrantManagementSupport@acdisaster.com

Phone: (352)-244-8338

Please Note: This form requires information and uploaded documentation that may take some time to gather for input. You will see the option to save and resume your form at the top and bottom of the page and you will receive an email with instructions on how to proceed if you do choose to save and resume.

Required Fields will be denoted with an asterisk (*). You may answer "Unknown" or "N/A" for required fields that are unknown or irrelevant to you.

Applicant First Name	Applicant Last Name
Applicant Birth Date	Applicant Age
Email	Cell Phone
Home Phone	Work Phone
Co-Applicant First Name	Co-Applicant Last Name
Co-Applicant Birth Date	Co-Applicant Age

Street Address Line 1	Street Address Line 2
Street City	Street State
Street Postal Code (First 5 digits)

Is your Street Address and Mailing Address the same?

Mailing Address Line 1	Mailing Address Line 2
Mailing City	Mailing State
Mailing Postal Code (First 5 digits)

All Household Members including Applicant and Co-Applicant:

Name	Last 4 Digits SSN	Date of Birth	Age	Relationship	Annual Income $

Is the Applicant, Co-Applicant, or any other household member aged 18 or older, a full-time student? If yes, please list household members:

Applicant Employment Information:

Employer Name:

Employee Name:

Position:

Supervisor:

Address Line 1

City

State

Postal Code (First 5 digits)

Phone

Fax

Pay Rate $

Pay Frequency

Co-Applicant Employment Information:

Employer Name:

Employee Name:

Position:

Supervisor:

Address Line 1

City

State

Postal Code (First 5 digits)

Phone

Fax

Pay Rate $

Pay Frequency

NOTE: Attach additional sheets as necessary for all household members 18 years and over and or for multi jobs.

Other Sources of Income (For ALL Household Members 18 and Over, List Business or Rental Net Income, Child Support, Alimony, Social Security, Pensions, Unemployment or Workers Compensation, Welfare Payments, etc.)

Name

Type of Income

Gross Annual Amount $

Assets and Asset Income (For ALL Household Members, Including Minors, List Checking and Savings Accounts, IRA, CD, Bonds, Stocks, Equity in Properties, etc.)

Type of Asset

Asset Value $

Bank/Account #

Ex: Bank of America/1394873

Annual Asset Income $

Is the applicant categorized as a special needs/developmental disabilities* individual pursuant to s. 420.0004 and s. 393.063, Florida Statutes?

*s. 420.0004 (13)“Person with special needs” means an adult person requiring independent living services in order to maintain housing or develop independent living skills and who has a disabling condition; a young adult formerly in foster care who is eligible for services under s. 409.1451(5); a survivor of domestic violence as defined in s. 741.28; or a person receiving benefits under the Social Security Disability Insurance (SSDI) program or the Supplemental Security Income (SSI) program or from veterans’ disability benefits.

s.420.0004 (7) “Disabling condition” means a diagnosable substance abuse disorder, serious mental illness, developmental disability, or chronic physical illness or disability, or the co-occurrence of two or more of these conditions, and a determination that the condition is: (a) Expected to be of long-continued and indefinite duration; and (b) Not expected to impair the ability of the person with special needs to live independently with appropriate supports.

s. 393.063 (9)“Developmental disability” means a disorder or syndrome that is attributable to retardation, cerebral palsy, autism, spina bifida, or Prader-Willi syndrome; that manifests before the age of 18; and that constitutes a substantial handicap that can reasonably be expected to continue indefinitely.

Special Needs (For reporting purposes only, please check all that apply for head of Household Only)For multiple options select CTRL+Click:

Ethnicity (For reporting purposes only, please check all that apply for head of Household Only) For multiple options select CTRL+Click:

LEVY COUNTY SHIP HOME REPAIR/REHABILITATION QUESTIONNAIRE

WHAT ASSISTANCE DO YOU WISH TO APPLY FOR?

Eligible Projects

Please provide the following information:

Do you live in Levy County?

Do you live within the city limits of a city?

If yes, what city?

Do you own this home?

If not, whose name (s) is the property deed in?

Do you live in the home currently?

If not, what is your current address?

Do you have any liens or judgments against this property?

If yes, what are they?

Are the property taxes current?

If no, what year(s) are still owed?

Have any of the repairs currently being requested been paid for by other funding, but not completed?

If yes, please explain:

Other miscellaneous information:

APPLICANT UNDERSTANDS THAT THE INFORMATION PROVIDED IS NEEDED TO DETERMINE SHIP ASSISTANCE ELIGIBILITY AND IN NO WAY ASSURES THAT THE APPLICANT WILL QUALIFY FOR ASSISTANCE. I/WE STATE THAT THE INFORMATION PROVIDED IS TRUE AND ACCURATE:

Please list and explain areas that need to be repaired:

Project Description: Please provide a detailed description of the project, including estimated timing for completion and any information you feel will be helpful for the County to determine eligibility.

Total Requested Funding Amount $:

Required Documentation

Please reference the Hurricane Housing Recovery Program Required Documents FAQ sheet for guidance.

1. Proof of Identification

Examples of Identification: Drivers License/Government Issued ID/Minor Birth Certificates

Upload Identification for relevant household members:

2. Proof of Household Income

Examples of household income: 2023 1040 tax return AND proof of submittal to the IRS from IRS.gov OR 2023 Tax Transcript, past two consecutive pay statements, current Social Security Award letter dated no more than 60 days, current Pension/ Retirement Letter dated no more than 60 days, current Disabilities Letter dated no more than 60 days, copy of Child Support/ Alimony and or Dissolution of Marriage

Court Order, copy of most recent bank statement

Upload Proof of Household Income for household members:

3. Proof of Ownership

Proof of Ownership Examples:

Warranty deed, Fee simple title, Mortgage statement, Private Contract for Sale,
99-year lease hold interest as lessee, Life Estate/Trust or Court Order/, Life Estate/Trust or Court Order/Affidavit/Succession, 2023 property tax statement.

Manufactured Housing Proof of Ownership Examples: Title, Bill of Sale, Registration Certificate, tax assessment statement, cash or contract deed, landowner consent (if on leased land)

Upload Proof of Ownership (One of the following listed above)

4. Proof of Primary Residence

Primary Residence Proof Examples: Homestead exemption on property as of August 30, 2023. If homestead exemption documentation is not available, please provide two of the following: 2021 Homestead tax exemption, letter or documentation from a government agency, driver’s license/government-issued ID, utility bills (electric, water, sewer, gas, cable, internet, homeowners insurance indicating primary residence.

Upload Proof of Primary Residence as listed above

5. Proof of Mortgage and Taxes in Good Standing

Examples of Mortgage/Tax Proof: Most recent mortgage statement OR payment plan in good standing with the current lender, Mortgage Satisfaction document (if home is owned free and clear), the current property tax receipt showing taxes have been paid or a copy of the property tax roll summary from the tax collector.

Upload Proof of Mortgage and Taxes in Good Standing

6. Tie Back to Hurricane Idalia

Examples of Hurricane Idalia Damage: Insurance estimate or claim, FEMA or SBA benefits, photographs of damage with a date stamp, construction permits, local/state government or nonprofit documentation, other documentation may be accepted.

Upload Proof of Hurricane Idalia Damage

7. Flood Zone

If the property received prior federal assistance, flood insurance documentation is required.

Upload Flood Zone Documentation

8. Disaster Assistance from Other Sources

Examples of other Disaster Assistance: FEMA or SBA award letter, homeowner or other insurance claims, assistance from non-profit organizations, any other sources of funds or assistance provided.

Upload Disaster Assistance from Other Sources

HURRICANE IDALIA AFFIDAVIT

In order to properly qualify for assistance, the applicants must be certified as individuals requesting assistance for damage as a result of the impact of Hurricane Idalia. Please read and sign to attest as applicable to your household.

Affidavit Date

On this date

I/We state that the assistance I/We am/are applying for is in relation to damage occurring as a result of Hurricane Idalia. This assistance will aid in mitigating any further damage to my/our property. I/We further state that I/We are not applying for assistance for which assistance has previously been received from any other Federal or State Funded Program associated with Hurricane Idalia.

I/we understand that Florida Statute 817 provides that willful false statements or misrepresentation concerning income; asset or liability information relating to financial condition is a misdemeanor of the first degree, punishable by fines and imprisonment provided under Statutes 775.082 or 775.83. I/we further understand that any willful misstatement of information will be grounds for disqualification. I/we certify that the application information provided is true and complete to the best of my/our knowledge. I/we consent to the disclosure of information for the purpose of income verification related to making a determination of my/our eligibility for program assistance. I/we agree to provide any documentation needed to assist in determining eligibility and are aware that all information and documents provided are a matter of public record.

Levy County and its funding sources collect your Social Security number for the following purposes, which are imperative for the performance of Levy County’s duties and responsibilities as prescribed in Part VII, Chapter 420, Florida Statutes and related regulations, and which are authorized under state law: classification of accounts, identification and verification, credit worthiness, billing and payments, data collection, reconciliation, tracking, benefit processing, tax reporting and qualification for grant or loan processing. Collection, use and release of Social Security numbers are governed under Section 119.071(5), Florida Statutes. Social Security numbers serve as a unique numeric identifier and may be used for such purposes.

By signing below, I/We acknowledge receipt of the Levy County Social Security Number Collection Policy disclosure.

Please Note: The option to sign will appear when you hit submit.

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