Housing Inspection Reimbursement Program

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Housing Inspection Reimbursement Program
PURPOSE: The purpose of the Home Inspections Reimbursement Program is to assist low-to-moderate AIAN families with home inspection costs incurred in order to determine and identify potential health and safety issues in a residential property.
SECTION 1: Applicant Eligibility Requirements
1. The applicant must not have received reimbursement for inspection services in the past.
2. The applicant’s annual income must not exceed the limits set by HUD adjusted for family size.
3. Families must meet the low to moderate income for the Ho-Chunk service area, which is annually published by HUD. Families that are not low income may be eligible for a reduced amount of assistance; this deduced calculation is based upon HUD Notice PIH-2014-02.
4. The applicant must not have any unpaid debts to the Ho-Chunk Housing & Community Development Agency, HCN Housing, other Tribal housing, or another HUD Housing Authority, will not be considered eligible.
5. Must be an enrolled member of a federally recognized tribe, preference will be given to enrolled Ho-Chunk members.
SECTION 2: Eligible Property Requirements
1. The property must be a single-family home, and be legally zoned for residential use.
2. New home construction is eligible.
3. Home cannot be in a flood plain unless there is flood insurance on the property.
4. Ineligible properties include but are not limited to: fixer uppers, rental or commercial properties, mobile homes or travel trailers, condominiums and multi-family apartment buildings.
5. Preference is given in HHCDA’s formula area of Adams, Clark, Columbia, Crawford, Dane, Eau Claire, Jackson, Juneau, La Crosse, Monroe, Sauk, Shawano, Trempealeau, Vernon, and Wood Counties.
SECTION 3: Allowable Activities

The two types of inspections allowed under this program are as follows
1. Home Inspection Services must be performed by a state-licensed independent home inspector.
2. Lead-Based Paint Risk Assessment for homes built on or before 1978 and must be performed by a state-certified lead risk assessor. Please take note that ‘do it yourself’ lead-paint testing kits do not qualify.
SECTION 4: Application Process

The applicant must submit the following information
a. Home Inspection Reimbursement Application – Attached

b. Income Verification

c. Copy of Tribal Enrollment

d. Copy of Social Security card.

e. Copies of inspection receipts indicating applicants name and amount paid.

f. Copy of inspection report(s) accompanied by a copy of the inspector’s license.

This program is funded by the U.S. Department of Housing and Urban Development (HUD) and compliance with applicable federal requirements must be adhered to.

HOUSING INSPECTION REIMBURSEMENT PROGRAM

RESPONSE TO COVID-19
The information will be used by the Ho-Chunk Housing and Community Development Agency to determine your eligibility for housing services.
APPLICANT INFORMATION
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Telephone

Area Code Phone Number
Email
example@example.com
Maiden Name
Tribal Affiliation
Enrollment Number
Type a question

Married Separated Unmarried (single, divorced, widowed)
Indicate your current housing arrangements:
Do you own a home?
Do you rent?
Are you an HHCDA tenant?
Is heat included in rent?

Please provide the following information on all members of the household:

Name

Relation to head of household

Age

Date of birth

Sex (M/F)

Social Security #

Enrollment #

Occupation

1. (Head of Household)

Annual Household Income

	1.) Household Member	2.) Gross Annual Income
1.
2.
3.
4.
5.
6.
Total Annual Gross Household Income (Add all "Gross Annual Income" amounts together in column 2)

Source of Income

	Source of Income
Wages & Tips
Per Capita
Retirement
Social Security
Disability
Other

1.) List the housing inspection service(s) you are requesting for reimbursement
1.) List the housing inspection service(s) you are requesting for reimbursement
APPLICANT STATEMENTS: I certify that all information given to Ho-Chunk Housing & Community Development Agency is accurate and complete to the best of my/our knowledge and belief. I understand that false information is punishable under law. I understand that false statements or information will make me ineligible for housing services.
Signature of Applicant

Clear
Date

Month Day Year
Date

Fair Housing and Equal Opportunity

If you believe you have been discriminated against, you may call the Fair Housing and Equal Opportunity National Toll-free Hot Line at 1-800-424-8590. After verification by this Housing Agency, the information will be submitted to the Department of Housing and Urban Development of form HUD 50058 Family Report, a computer generated facsimile. See the Federal Privacy Act Statement for more information about its use.
FEDERAL PRIVACY ACT

The U.S. Department of Housing and Urban Development (HUD) will be collecting information you gave to the Ho-Chunk Housing and Community Development Agency at application or reexamination. HUD will collect the information on Form HUD 50058. The data it will collect includes name, sex, birth date, Social Security Number (SSN), income (by source), assets, certain deductible expenses, and rental payment. The Privacy Act of 1974, as amended, requires us to tell about this. We also are required to tell you what HUD will do with the information. HUD will use the information to manage and monitor HUD assisted housing programs. It also may verify whether the information is accurate and complete by doing a computer match. HUD may give the information to Federal, State, and local agencies when it will be used for civil, criminal or regulatory investigations and prosecutions. HUD also may make summaries of resident data available to the public. Other than these uses, HUD will not release the information outside HUD, except as permitted or required by law. The Housing and Community Development Act of 1987, 42 U.S.C. 3543 requires applicant and residents to give the HHCDA the SSN(s) of household members at least six (6) years old. lfyou are an applicant and you have been issued or use SSN(s) and you do not give them to the HHCDA, the HC Housing and Community Development Agency is required to reject your application for housing assistance. If you are receiving housing assistance and you have been issued or use SSN(s) and you do not give them to the HHCDA, the HC Housing and Community Development Agency is required to evict your family or withdraw your housing assistance. The U.S. Housing Act of 1937, as amended 42 U.S.C. et. Seq., and the Housing and Community Development Act of 1981, P.L. 97-35, 85 stat., 348,408 require applicants and residents to provide the other information listed in the first paragraph to the HC Housing and Community Development Agency. If you are an applicant and you fail to give the HHCDA this information, the HHCDA may have to reject your application or delay acting on it. If you are receiving housing assistance and you do not give the HC Housing and Community Development Agency this information the HHCDA may have to evict you or withdraw your housing assistance. I have read and fully understand the Federal Privacy Act Statement:
Printed name of applicant

Clear
Date

Month Day Year
Date

AUTHORIZATION FOR THE RELEASE OF INFORMATION
I, the undersigned, with this, authorize the Ho-Chunk Housing and Community Development Agency and their agents to obtain any information, necessary, to process the HUD housing application. This information may be obtained from the following sources, any of the programs of the Ho-Chunk Nation, federal, state, and local governments and any of their agencies and representative, law enforcement agencies, financial institutions and current and prior landlords. This list is not all-inclusive and may include any additional agency, government, or private source, as deemed necessary by the Ho-Chunk Housing and Community Development Agency and/or their agents.

I, the undersigned, with this, release the Ho-Chunk Housing and Community Development Agency and/or their agents any requested information from the following agencies: federal, state and local governments, law enforcement agencies, financial institutions, and current or prior landlords.

This information requested may be given by fax, telephone or in writing. This release is valid for fifteen (15) months from the date of the applicant’s signature. This release is valid if photocopied and does not have to have an original signature.

I, have read the terms and conditions of the AUTHORIZATION FOR THE RELEASE OF INFORMATION and with this, give consent for the release of any requested information.
Printed name of applicant

Clear
Applicant Signature

Clear
Date

Month Day Year
Date
SSN of applicant
Date of birth of applicant

Month Day Year
Date

Applicant
So we can better process your application please be sure to include the following information:
- Application – complete and signed
- Income verification for each adult family member– last three paycheck stubs, SSI statement, unemployment statement, pension etc. or copy of recent federal income tax return
- Copies of social security card and verification of tribal enrollment
- Paid receipt for reimbursement with copy of inspector’s license and report
- Signed Release of Information
- Signed Privacy Act Statement
Only applications that have the above-mentioned documents completed can be processed.

Please check each box and include this with your application packet.
Signature of applicant

Clear
Date

Month Day Year
Date
Should be Empty:

Directions

Housing Inspection Reimbursement Program

SECTION 1: Applicant Eligibility Requirements

SECTION 2: Eligible Property Requirements

SECTION 3: Allowable Activities

SECTION 4: Application Process

HOUSING INSPECTION REIMBURSEMENT PROGRAM

APPLICANT INFORMATION

Fair Housing and Equal Opportunity

AUTHORIZATION FOR THE RELEASE OF INFORMATION

Applicant