Homebuyer Set Up and Completion Form SETUP

HOME Program COMPLETION

Check the appropriate box:
Original Submission Revision / Name and Phone Number of Person Completing Form:

A. General Information. CONTRACT #:

1. Name of Participant: / 2. IDIS Activity ID: / 3. Activity Name (property address only):

B. CHDO Questions.

1. Is funding limited to CHDO Operating (CO) or CHDO Capacity Building (CC)? N
2. Will activity be funded with CR (CHDO setaside)? Y N / 3. Is the CHDO acting as (check one):
(1) Owner (2) Sponsor (3) Developer
4. Will initial funding be CHDO site control and/or seed money loan? N / 5. Is the activity going forward? N/A
FOR MFA USE ONLY / OBJECTIVE: [ ] 1 Suitable Living Environments / OUTCOME: [ ] 1 Availability/Accessibility [X] 2 Affordability
[X]2 Decent Affordable Housing [ ]3 Create economic opportunities / [ ]3 Sustainability

C. Activity Information.

1. Activity Type (check one): (1) New Construction Only (2) Acquisition Only (3) Acquisition & Rehab (4) Acquisition & New Construction
2. Homebuyer’s Name: / 3. Street Address:
4. City: / 5. State: NM / 6. Zip Code: / 7. County Code: / 8. Est. HOME Units:
9. Est. HOME Cost:
$0.00 / 10. Region Served:
Colonias Tribal Other / 11. Is this participant a faith-based organization?
Y N
12. Multi-address Y N / 13. Loan Guarantee Y N

D. FOR MULTI-ADDRESS ACTIVITIES ONLY

DEVELOPER / 1. Type (Check one)
(1) Individual (2) Partnership (3) Corporation (4) Not-for-Profit (5) Publicly Owned (6) Other
2. Developer Name / 3. Street Address
4. City: / 5. State: / 5. Zip Code:

AT COMPLETION:

1. Property Type (check one):
(1) 1-4 Single Family (3) Cooperative (2) Condominium (4) Manufactured Home / 2. Environmental Assessment Code:
A-Exempt C-Completed D-Underway
3. Lead Paint
Applicable Lead Paint Requirement: Housing constructed before 1978 Exempt: housing constructed 1978 or later Otherwise exempt
Lead Hazard Remediation Actions: Visual Assessment/Paint Stabilization (24 CFR 35.1015) Other Actions required by Local/State Codes
Total / Home-Assisted / 4. Period of Affordability: If you are imposing a period of affordability that is longer than the reg. minimum, enter the total years (HOME + additional) of affordability.
PJ-imposed period of affordability: [ ] YEARS
COMPLETED UNITS:
Of the Completed Units, the number:
Meeting Energy Star Standards:
504 Accessible:
5. Purchase Price: $0.00 / 6. Value after Rehab (for acq/rehab only) $0.00

E. ACTIVITY COSTS:

1. HOME Funds (Including Program Income)

a. Property Costs Totals

(1) Amortized Loan / $0.00
(2) Grant / $0.00
(3) Deferred Payment Loan (DPL) / $0.00
(4) Other / $0.00

b. Downpayment Assistance

(1) Amortized Loan / $0.00
(2) Grant / $0.00
(3) Deferred Payment Loan (DPL) / $0.00
(4) Other (Fees to Non-Profits – Homebuyer Counseling and HQS) / $0.00
c. CHDO Loan / $0.00
Total HOME Funds [a + b + c] / $0.00

MFA USE ONLY

CHDO CERTIFICATION / FUNDING CERTIFICATION / Federal Compliance Period (Yrs) / Approved / Date


2. Public Funds

(1) Other Federal Funds / $0.00
(2) State/Local Funds / $0.00
(3) Tax Exempt Bond Proceeds / $0.00
Total Public Funds [(1) + (2) + (3)] / $0.00

3. Private Funds

(1) Private Loans / $0.00
(2) Owner Cash Contribution / $0.00
(3) Private Grants / $0.00
Total Private Funds [(1) + (2) + (3)] / $0.00
4. Activity Total (Sum All Totals) / $0.00

F. Household Characteristics. (Refer to codes below where applicable)

HOUSEHOLD /
# of Bdrms / Occupant / % Med / Hispanic?
Y/N / Race / Size / Type / Assistance Type /
Female Head
Household? Y/N
/ Is Head Disabled?
Y/N
2
2
1. Homebuyer Counseling? (Check one)
(1) No Counseling (3) Post-counseling
(2) Pre-counseling (4) Both / 2. First-time Homebuyer?
Y N / 3. Coming from subsidized housing?
Y N
(for multi-address activities)
4. Lease Purchase? Y N If yes, date of agreement: FHA Insured? Y/N

Page 2 of 2 Revised (1/12)