SECURITY DEPOSIT ASSISTANCE PROGRAM
APPLICATION
Applications will be deemed incomplete until the items listed below are received.
Please complete the application and return it with copies of the following items that apply. Please check the items you will be supplying with your application. Do not enclose originals unless the City of Bend may keep them.
o A copy of the two most recent pay stubs from all employed in the household. (Please ensure the employee's name and employer's name and address are on the pay stub as well). AND copies of the last (3) months bank statements of all checking/savings accounts, OR, A copy of your most current federal tax return with a copy of pertinent W-2s (If you do not have a bank account, please write a statement to that matter and sign it.)
o Statements of all household income and assets. (Examples: Benefit statement from social security, disability or other type of support or income, Financial Aid, Current retirement or pension accounts, including 401ks, and IRAs, child support or alimony {income or liability}
o If you are self-employed, provide a year to date profit and loss statement and balance sheet.
o If the home is shared with a roommate(s), the requested income (including any financial aid) and bank statements or tax information also applies separately for them. This is also required for adult aged children living in the home.
o A copy of Oregon Drivers’ License for all applicants
o Loan amount may not exceed 40% of household income; maximum loan amount is $600
o Copy of lease from new landlord showing move-in costs and security deposit amount. (If loan is less than full security deposit amount, you must provide proof of payment for outstanding balance.)
o Certificates of completion of FDIC Money Smart Financial Education Program, which is a set of 12 training modules covering financial topics. A certificate of completion for all courses must accompany application. https://www.saltmoney.org/index.html#
o Assistance is limited to one time benefit.
o Your HOUSEHOLD INCOME (this means the combined earnings of all adult persons living in the house) per year must be no more than the amounts shown in the following table:
1 person / 2 person / 3 person / 4 person / 5 person / 6 person / 7 person / 8 person / Additional$34,950 / $39,950 / $44,950 / $49,900 / $53,900 / $57,900 / $61,900 / $65,900 / Add $3,700
Income Limits-2014
The undersigned agrees to and understands all program guidelines. The undersigned further assures all information contained in this application is true and correct.
Applicant Date
Co-Applicant Date
Applicant Name / Social Security #Co-Applicant Name / Social Security #
Current Address
______
______
How long have you lived at this address? / Current Cell/ Home Phone
Applicant Work Phone
______
Email Address: / Co-Applicant Work Phone
Date of Birth: Applicant:
Co-Applicant: / Driver’s License/ ID #: Applicant:
Co-Applicant:
What is your current living situation? / Are you or your spouse/dependent active duty military?
Total number in household Ages______
Applicant’s Employer Name Length of Employment
Employer’s Address
Full time______Part time______Paid biweekly______Paid weekly_____ Paid Monthly_____
Co-Applicant Employer’s Name Length of Employment
Employer’s Address
Full time______Part time______Paid biweekly______Paid weekly_____ Paid Monthly_____
Bank Information:
Bank name______Bank telephone number:______
References:
Name______
Phone Numbers______
Name______
Phone Numbers______
Loan Amount Requested______
Gross Monthly Income: / Applicant / Co-Applicant / Total / Rec’d DocsWages / $ / $ / $
Unemployment / $ / $ / $
Food Stamps or SNAP / $ / $ / $
TANF / $ / $ / $
Alimony and/or
Child Support / $ / $ / $
Rental Assistance / $ / $ / $
Retirement / $ / $ / $
SSI/SSN / $ / $ / $
Other
Current Bank Stmts (3) c Yes c No Including Savings
Household Information:
Client name:
Additional members:
Single headed household? Yes _____ No_____ Female______Male______
Is the household in a situation of homelessness? Yes _____ No _____
Please indicate the total number of persons in the family* identified by the client as a member of each special needs category.
SPECIAL NEEDS & HOMELESS / total number of family membersElderly persons
Persons with developmental disabilities
Persons with physical disabilities
Persons with HIV/AIDS
Persons with mental illness
Persons with substance abuse problems
Migrant agricultural workers
TOTAL
Applicant Race (please mark one)
White o Black or African American o
American Indian/Alaskan Native o Asian o
Native Hawaiian/Other Pacific Islander o American Indian/ Alaskan and White o
Asian and White o Black/African American and White o
American Indian/Alaskan and Black o Other o
Applicant Ethnicity (You should select both a “Race” category and “yes” or “no” for Hispanic Origin:
Hispanic?: o Yes o No
If yes, please circle one: Cuban Puerto Rican Mexican/Chicano Other Hispanic/Latino
This information is required pursuant to Federal Guidelines for this assistance program, but does not affect an applicant’s eligibility.
Do you currently have outstanding payday loans? Yes_____ No_____
Do you have a pending bankruptcy? Yes____ No_____
Security Deposit Assistance Program Application Page 1 of 7
Borrower/Co-Borrower must review and initial each section below:
______I (we) certify that total household income for ALL occupants of the household does not Initials exceed 80% of the HUD median income, adjusted for family size and location, as calculated based on the Income Eligibility Calculated located at http://www.hud.gov/offices/cpd/affordablehousing/training/web/calculator/calculator.cfm.
NOTE:
Funding is limited and may not be sufficient to fund all applications. Therefore, applications will be processed in the order in which they are received. Incomplete applications will not be considered.
Initials of Applicant/Co-Applicant /
For purposes of verifying the above information, I authorize Families Forward and its contractors, affiliates, or agents to contact any persons or companies to verify information Families Forward may require now or in the future while performing a loan service for me or in recovering any debt I owe to Families Forward. I authorize Families Forward and its contractors, affiliates, or agents to request and receive credit reports from time to time pertaining to me from any Consumer Credit Reporting Agency. I further acknowledge that I have received Families Forward Privacy Policy and understand the privacy options. By signing below, I hereby verify that the information presented here is true and accurate to the best of my knowledge, and if asked can prove accuracy of the information. I acknowledge that Families Forward may report information about a loan I receive to credit bureaus. This may include late payments, missed payments or other defaults on such loans. I further agree to notify Families Forward of any change in name, address, telephone number, employer, or any other change in my situation.
Applicant Signature:______Date:______
Co-Applicant Signature: ______Date ______
Public Records and Confidentiality of Application. By submitting an Application, the Applicant acknowledges that information submitted to the City of Bend is open to public inspection under the Oregon Public Records Law, ORS 192.410 through 192.505. One (1) copy of each original Application shall be kept for the City of Bend for a minimum period of one (_1_) years. The Applicant is responsible for becoming familiar with and understanding the provisions of the Public Records Law.
The Applicant may identify information submitted to the City as confidential. Prior to submitting such information to the City, the Applicant shall prominently mark in conspicuous letter any information with the words ‘Confidential Information” and state in writing that the Applicant wishes the material to be held in confidence and the reasons therefore. The City may treat any information so marked as confidential and not subject to public disclosure, to the extent permitted by law. If the City receives any public records request for disclosure of such information, within ten (10) City working days of receiving any such request, the City shall provide the Applicant with written notice of the request, including a copy of the request. The Applicant shall have ten (10) City working days within which to provide a written response to the City, before the City may disclose any of the requested confidential information. Whether the Applicant submits any written response to the City, the City shall retain the final discretion to determine whether to release the receipt of any response from the Applicant prior to releasing such information. The Applicant does not waive any rights to seek a protective order from a court of competent jurisdiction restraining the City from disclosing such information.
Part 5 Annual Income Calculation Worksheet1. Name: / 2. Identification:
ASSETS
Household Member / Asset Description / Current Cash Value of Assets / Actual Income from Assets
3. Net Cash Value of Assets ……………. / $
4. Total Actual Income from Assets ………………………………………. / $
5. If line 3 is greater than $5,000, enter Passbook Rate %; otherwise, leave blank. / Passbook Rate: / 0.02 / $
ANTICIPATED ANNUAL INCOME
Household Member / Wages/Salaries / Benefits/Pensions / Public Assistance / Other Income / Asset income
The greater of lines 4 or 5 from above should be in cell below:
6. Totals / $0 / $ / $ / $ / $
7. Total of items from 6a. Through 6e is Annual Income……………………………… / $
Applicant Signature / Date
Household Income: / $
Income Level:
Signature of Certifying Staff / Date
Security Deposit Assistance Program Application Page 1 of 7