City of Topeka Neighborhood Relations
620 S.E. Madison ST, 1st FL, Unit 8 Topeka, KS 66607
Phone: (785) 368-3711
FAX: (785) 368-2546
APPLICATION FOR ASSISTANCE –Owner Occupant
Application Date: _______________
Owner e-mail address: _______________________________
Application
Number
Assigned:
PROPERTY ADDRESS: ___________________________________
Zip Code: __________________
Applicants Name: ________________________________________________________________________________
Last
First
Middle
Soc.Sec.#
Age
Date of Birth
Co-Applicant: ____________________________________________________________________________________
Last
First
Middle
Soc.Sec. #
Age
Date of Birth
Phone Numbers: HOME: ___________________ WORK: ___________________ CELL ____________________
Email Address: ________________________________________
=============================================================================
ALL OTHER OCCUPANTS: (All family and non-family members residing with you currently or shall reside with
you in the next residence as participants of any housing program. Include roommates, co-habitants, friends or
acquaints.)
Name
Social Security Number
Relationship
Age
Date of Birth
.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Income
Persons:
---1-- ---2-- ---3-- ---4-- ---5-- ---6-- ---7-- ---8-Rehab:
Emergency Rehab:
80% Median:
60% Median:
35,100 40,100 45,100 50,100 54,150 58,150 62,150 66,150 (Mar. 28, 2016)
26,300 30,050 33,800 37,550 40,550 43,550 46,550 49,550
I wish to be considered for housing assistance from Neighborhood Relations. I understand that my application is no
guarantee of assistance, but that it does entitle me to fair and impartial consideration along with other applicants for assistance.
Application is subject to client eligibility, program eligibility, available funding and any other pre-approvals and the program is
subject to change, or discontinuance at any time without notice.
I give all the information in this application, and all the information furnished in support of this application, for the purpose
of obtaining assistance under the Community Development Act of 1974 and it is true and complete to the best of my knowledge and
belief.
I further understand that, in order to determine my eligibility for assistance, Neighborhood Relations staff will be required to
obtain detailed information on my financial status, employment, home ownership and occupancy.
I understand that it is a federal crime (U.S.C. Title 18, Sec. 1001) to knowingly make any false statements concerning my
facts herein.
“I realize that the City may wish to use the work it has done to my house for proof of its work or advertising. By signing this
application, I/we grant the City my/our consent to take photographs of my/our house and grounds before, as well as after construction
and realize that the photographs may be displayed to the public in print as well as electronically for the City’s benefit.”
I understand disclosure of information contained within this application will only be made if required by federal, state, or
local law.
Signature of Applicants
Signature of Applicants
_____________________________________
_____________________________________
Date: ________________________________
Date: ___________________________________
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The program applicant has a right to request modifications of program policies, procedures or practice to
accommodate their individual disability. Requests for such modifications should be made on the line below.
Request: ________________________________________________________________________________
EARNINGS or INCOME (During Past 12 months): Employment, Business Earnings, Self Employment,
Real Estate Rental, Social Security, Pensions, VA, Annuities, Child Support, Alimony, Welfare, Food Stamps.
Specify Income as Weekly, Monthly, Temporary, No Longer Receiving, etc. Documentation of occupant
income must be returned with this application and consist of such items as IRS Tax Account Transcript (800)
829-1040, completed income verification form, copies of three consecutive paycheck stubs, copies of monthly
Social Security or Social and Rehabilitation Services payments, copies of pension or annuity payments, copies
of child support payments, copies of incomes from certificates of deposits or bank accounts.
NAME
SOURCES
ACCOUNT NO.
PAY PERIOD
INCOME
$
TOTAL ANNUAL
GROSS INCOME
$
ASSETS:
List all Liquid Assets such as any Bank Accounts (checking, savings, and CD’s), Stocks, Bonds, Funds, Autos, Mobile Homes, etc.,
and other Real Estate or Business Interests.
NAME & LOCATION
ACCOUNT
NUMBER
VALUE
AVERAGE
ACCOUNT
BALANCE
CURRENT
ACCOUNT
BALANCE
PROPERTY CHARACTERISTICS: May not know
Occupied Since: ___________
Please include a photo copy of a government issued identification with picture:
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PROPERTY CHARACTERISTICS:
Date Purchased: __________
Do you have Homeowner’s Insurance?: __________
Type of Ownership: Deed:
Other: __________ Contract for Deed:
________________ Life Estate:
__________
__________
__________
Occupied Since: __________
Insurance Agent/Company(Address & Phone Number):
__________________________________
__________________________________
__________________________________
__________________________________
Mortgage Holder (Address & Phone Number):
___________________________________
___________________________________
Contract For Deed Seller (Address & Phone Number):
________________________________________
________________________________________
Account #
_____________________________
Escrow Holder (Address & Phone Number):
_______________________________________
VOLUNTARY INFORMATION FOR GOVERNMENT MONITORING PURPOSES:
Applicant: I Do Not Wish to Furnish This Information: ____________________
(initial)
If not completed, NR staff will complete to the best of their ability because of HUD requirements.
ETHNICITY:
[___] HS Hispanic / Latino
[___] NHS Not Hispanic / Latino
GENDER:
[___] Female
[___] Male
RACE / NATIONAL ORIGIN:
(This category must be completed)
[__] AI
American Indian / Alaskan Native
[__] AS
Asian
[__] BA Black / African American
[__] HI Native Hawaiian / Other Pacific Islander
Female Headed Household:
[___] YES
[___] NO
[__] WH White
[__] IW
American Indian / Alaskan Native & White
Age (over 62):
[___] YES
[___] NO
[__] AW Asian & White
[__] BW Black / African American & White
[__] IB American Indian / Alaskan Native
& Black / African American
[__] OT Balance / Other
Disability:
[___] YES
[___] NO
Description of Repairs Requested/Additional Notes / Information:
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CITY OF TOPEKA
========================================================================
Neighborhood Relations
February 2015
620 S.E. Madison Street, 1st Floor, Unit 8
Topeka, Kansas 66607
Phone: (785) 368-3711
FAX: (785) 368-2546
AUTHORIZATION
for
RELEASE of FINANCIAL INFORMATION
I/We,
(Printed Name)
(Signature)
(Date)
________________________
________________________
________
________________________
________________________
________
________________________
________________________
________
________________________
________________________
________
________________________
________________________
________
residing at _____________________________________________, in Topeka,
Kansas, do hereby grant authorization for the release of detailed and accurate financial
information to Neighborhood Relations, on my financial status, credit, income, employment
circumstances, all utilities, occupancy, and ownership of the above property which
authorization shall be effective for a three [3] month period. I/We grant this authorization so
that this property may be considered for assistance from The City of Topeka Department of
Neighborhood Relations (a municipal corporation.
I/We authorize the use of photocopies of this document, which shall be as effective as
the original for the stated purpose above. I/We also grant authorization for the Release of
Information to be FAXed.
The City of Topeka Is An Equal Opportunity Employer
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CITY OF TOPEKA
==========================================================================
Neighborhood Relations
February 2015
620 S.E. Madison Street, 1st Floor, Unit 8
Topeka, Kansas 66607
Phone: (785) 368-3711
FAX: (785) 368-2546
HUMAN RES/PERSONNEL DEPT
INCOME VERIFICATION FORM
_______________________________
(Name of Employer)
The employee listed below request in this signed authorization form that you as his
employer verify employment income as required by Federal Regulations by completing and
returning this document to Neighborhood Relations at the address printed in the heading of
this page. This information will be used only to determine the eligibility status and level of
benefit of the household. Your prompt return of the requested information will be appreciated.
______________
Employee Name
____________________
Social Security Number
___________
Date of Birth
Employee Address: ____________________________
- Date Employment Began: ____________ Date Employment Ended___________
- Possibility of Continued Employment________
- Base Pay Rate: $_____/Hour; or $_____/Week; or $_____/Month
- Average Hours Per Week Employed _____
(Yes) ___ (No___
- No. Weeks ____, or No. Weeks ____ Worked Per Year
- Is Overtime expected (Yes) ____ (No) ____
- No. of Overtime Hours Expected/Week over the next 12 Months ____
- Overtime Pay Rate ______/Hour
- Other Compensation Not Included Above (Commissions, Bonuses, Tips, Etc.)
For: _______________________ $______ per__________
- Is Pay Received For Vacation? _____ If Yes, No. of Days/Yr. ____
- Total Base Pay Earning For Past 12 Months $__________
- Total Overtime Earnings For Past 12 Months $__________
- Probability And Expected Date Of Any Pay Increase __________
-Does The Employee Have Access To A Retirement Account ____ Yes ____ No
- If Yes, What Amount Can They Get Access To $______
- Employment Status:
Permanent _____
Seasonal _____ From:_______________ To _____________
Date Seasonal Employment will end: ____________
Temporary ____ If Yes, Date Temporary Employment will end: __________
Other Relevant Income Information:
___________________________________________________________________________________
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___________________________________________________________________________________
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________________________________
Authorized Representative Name
________________________________
Authorized Representative Signature
__________________
Date
__________________
Phone No.
Please supply the requested information and return to this department. I can be contacted at (785) 3683711 if you have any questions.
Sincerely,
Tony Salazar
Community Resource Specialist
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.
RELEASE: I hereby authorize the release of the requested information.
__________________________________
Name of Applicant
__________________________________
Signature of Applicant
Date: ____________________________
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