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HomeMy WebLinkAboutCDC/2000-24 1 RESOLUTION NO: CDC/2000-24 2 3 RESOLUTION OF THE COMMUNITY DEVELOPMENT COMMISSION APPROVING THE FIRST AMENDMENT TO THE AGREEMENT BETWEEN NEIGHBORHOOD HOUSING SERVICES OF THE INLAND EMPIRE, INC., AND THE REDEVELOPMENT AGENCY, DATED SEPTEMBER 7, 1999, TO ADD THE MAINTENANCE GRANT PROGRAM TO THE SINGLE FAMILY HOME IMPROVEMENT LOAN AND BEAUTIFICATION GRANT PROGRAM AGREEMENT 4 5 6 THE COMMUNITY DEVELOPMENT COMMISSION ACTING ON BEHALF OF TH 7 REDEVELOPMENT AGENCY OF THE CITY OF SAN BERNARDINO DOES HEREBY RESOLVE DETERMINE, AND ORDER AS FOLLOWS: 8 9 SECTION I. The Executive Director of the Redevelopment Agency ("Agency") is hereby authorized 10 and directed to execute on behalf of said Agency the First Amendment to the Agreement between the Agency and 11 Neighborhood Housing Services of the Inland Empire Inc., (NHSIE) dated September 7,1999, in order to allocate 12 the additional sum of $350,000, for a total allocation of $850,000 from the Agency's Low and Moderate Income 13 Housing Fund to NHSIE to add the Citywide Maintenance Grant Program to the Single Family Home Improvement 14 Loan and Beautification Grant Program as per the provisions of the First Amendment to the Agreement, a copy of 15 which is on file with the City Clerk and incorporated herein by reference as though fully set forth at length. 16 SECTION 2. The Executive Director ofthe Agency is hereby authorized to make minor corrections, 17 additions, and clarifications to the Agreement, provided said changes are not substantive in nature, and do not 18 increase the monetary impact to the Agency. 19 SECTION 3. For purposes of satisfying the requirements of Health and Safety Code Section 33413(b), the 20 Commission hereby finds and determines that the Maintenance Grant Program expands and preserves the 21 community's supply of affordable housing with a benefit to such supply equal to fifteen (15) units of affordable 22 housing. The basis of this finding is that the Commission presently estimates that 159 households shall participate 23 in Maintenance Grant Program transactions and that each such household shall have an adjusted household income 24 which is not greater than a low-income household, and accordingly, on average each household which is qualified to 25 participate in the Maintenance Grant Program shall receive $2,000 in rehabilitation assistance (net of amounts 26 payable to NHSIE as administrator of the Maintenance Grant Program). 27 SECTION 4. The authorization to execute the above referenced First Amendment to the Agreement is 28 rescinded if the parties fail to execute it within sixty (60) days of the passage of this Resolution. 1 NilS Single Amend 07/24/00 CDC/2000-24 1 RESOLUTION OF THE COMMUNITY DEVELOPMENT COMMISSION APPROVING THE FIRST AMENDMENT TO THE AGREEMENT BETWEEN NEIGHBORHOOD HOUSING SERVICES OF THE INLAND EMPIRE, INC., AND THE REDEVELOPMENT AGENCY, DATED SEPTEMBER 7, 1999, TO ADD THE MAINTENANCE GRANT PROGRAM TO THE SINGLE FAMILY HOME IMPROVEMENT LOAN AND BEAUTIFICATION GRANT PROGRAM AGREEMENT 2 3 4 5 I HEREBY CERTIFY that the foregoing resolution was duly adopted by Community Development Jo~nt Commission of the City of San Bernardino at aRegular meeting thereof, held on 24 th day of 6 7 July , 2000 by the following vote, to wit: 8 9 COMMISSION MEMBERS: AYES NAYS ABSTAIN ABSENT ESTRADA X LIEN X MCGINNIS X SCHNETZ X SUAREZ x ANDERSON X MC CAMMACK X 10 11 12 13 14 15 ~h.~ 16 17 18 The foregoing resolution is hereby approved this1~ .- day of July ,2000. 19 20 21 s, Chairperson ity Development Commission ity of San Bernardino 22 23 Approved as to form and Legal Content: James F. P/rn an, City Atto y \ I 24 25 By: 26 27 28 2 NHS Single Amend 07/24/00 CDC/2000-24 REDEVELOPMENT AGENCY OF THE CITY OF SAN BERNARDINO 2 AMENDMENT NO. 1 TO THE AGREEMENT FOR THE SINGLE FAMILY HOME IMPROVEMENT AND BEAUTIFICATION REHABILITATION LOANS AND GRANTS PROGRAM ORIGINATION AND SERVICE ASSISTANCE, DATED SEPTEMBER 7, 1999 (Neighborhood Housing Services of the Inland Empire, Inc.) 3 4 5 6 THIS AMENDMENT NO. 1 (the "Amendment No.1") to the 7 Agreement dated September 7, 1999, is made and entered into as 8 of this 24th day of July 2000, by and between the Redevelopment 9 Agency of the City of San Bernardino, a public body corporate JO and politic (the "Agency"), and Neighborhood Housing Services of 11 the Inland Empire, Inc., a California non-profit corporation, 12 (the "Consultant") in view of the facts set forth in the 13 following Recitals: 14 15 RECITALS 16 17 The Agency and Consultant have previously entered into the 18 Agreement for the purpose of allowing the Agency to implement 19 its affordable housing improvement program known as the "Single 20 Family Home Improvement and Beautification Loans and Grants 21 Program" in certain areas of the City of San Bernardino (the 22 "City") described in the Agreement as "Neighborhood Initiative 23 Target Area-NIP Areas"; and 24 25 SBEO/000l/DOC/4128-1 7/19/00 915 jrnw 1 CDC/2000-24 The Agency and Consultant desire to implement an owner- 2 occupant single family housing rehabilitation and repair grant 3 program city-wide as the basis (described herein on a 4 "Maintenance Grant Program") using the special source of Agenc 5 low-and moderate-income housing funds described in Section 3 of 6 this provided however that the Amendment 1, below; No. 7 Maintenance Grant Program shall only be available to "Qualifie 8 Homeowners", defined in the Agreement, adjuste whose as 9 household income does not exceed 80% of San Bernardino Count 10 median household income. 1] ]2 NOW, THEREFORE, IN CONSIDERATION OF THE MUTUAL COVENANTS 13 HEREIN SET FORTH AND THE MUTUAL BENEFITS TO BE DERIVE 14 THEREFROM, THE CONSULTANT AND THE AGENCY HERETO AGREE AS 15 FOLLOWS: 16 17 Section 1. The meaning of words and phrases as used in 18 this Amendment No. 1 shall be the same as set forth in the ]9 Agreement except as the context of usage of a particular term or 20 phrase as set forth in the text of this Amendment No. 1 ma 21 require. all exhibits The of the Agreement (and text 22 accompanying the Agreement) is hereby incorporated into this 23 Amendment No. 1 by this reference. 24 25 SBE010001/DOC/4128-1 7/19/00 915 jrnw 2 CDC/2000-24 Section 2. The Consultant and the Agency mutuall 2 acknowledge and agree that as of the date of approval of this 3 Amendment No. 1 by the governing board of the Agency, no default 4 exists under the Agreement, nor is either party aware of an 5 fact, with the giving of notice and the passage of time, woul 6 constitute a default under the Agreement. 7 8 Section 3. Nothing in this Amendment No. 1 shall be 9 deemed to affect the allocation of the low- and moderate-income 10 housing funds of the Agency in the amount of Five Hundre 11 Thousand Dollars ($500,000.00) as previously reserved for the 12 implementation of the Program in Agency-Designated Neighborhoods 13 pursuant to the Agreement. This Amendment No. 1 provides for an 14 allocation of a separate and additional sum of Agency Fiscal 15 Year 2000-01 low-and moderate-income housing funds in the amount 16 of Three Hundred Fifty Thousand Dollars ($350,000.00) to be use 17 solely for the Maintenance Grant Program in accordance with 18 Section 4 through Section 13 of this Amendment No. 1 to the 19 Agreement. No other source of City or Agency funds is reserve 20 or made available for the implementation of the Maintenance 21 Grant Program. The total aggregate amount of affordable single n family dwelling maintenance and rehabilitation grants which ma 23 be originated under the Maintenance Grant Program shall not 24 exceed the sum or $350,000.00, inclusive of compensation payable 25 by the Agency to the Consultant for such affordable single SBEO/0001/DOC/4128-1 7/19/00 915 jrnw 3 CDCj2000-24 family dwelling maintenance and rehabilitation grants originate 2 under the Maintenance Grant Program. 3 4 The Agreement is hereby amended to add a ne Section 4. 5 Section 21 which reads as follows: 6 7 AMENDMENT NO. 1 TO AGREEMENT AND MAINTENANC "Section 21, 8 GRANT PROGRAM. Pursuant to the terms of Amendment No. 1 t 9 this Agreement the Agency has retained the Services of th 10 Consultant to implement the Maintenance Grant Program on 11 city-wide basis. Each transaction as originated an 12 completed by the Consultant under the Maintenance Gran 13 Program shall be a grant transaction between the Agency an 14 a Qualified Homeowner. The proceeds of each "Program Loan" 15 grant transaction under the Maintenance Grant Program shall 16 not be repayable by the Qualified Homeowner to the Agency; 17 provided that all of the representations and warranties 0 18 the Qualified homeowner to the Agency in the Program 19 (Maintenance Grant Program) are true Application 20 correct. In the case of a Maintenance Program 21 transaction, the use of certain defined terms and word suc 22 as "Program Loan" and "Program Loan Documents" accordingl 23 refer to the special underlying grant transaction documents 24 evidencing the Maintenance Program Grant between 25 Qualified Homeowner and the Agency." SBEO/0001/DOC/4128-1 7/19/00 915 jrnw 4 CDC/2000-24 2 Section 5. Section 1 of the Agreement is hereby amende 3 to add a new defined term of "Maintenance Grant Program" as 4 follows: 5 6 "Maintenance Grant Program" means and refers to th " 7 owner-occupied single family dwelling unit repair an 8 grant program of the Agency rehabilitation as mor 9 specifically described in Exhibit "D" attached hereto an 10 as approved as part of Amendment No.1 to the Agreement." 11 12 Section 1 of the Agreement is hereby amende Section 6. 13 to modify the definition of the term "Program Loan" to read as 14 follows: 15 16 "Program Loan" means and refers to each single " 17 home improvement and beautification loan and/or 18 transaction by and between a Qualified Homeowner and th 19 Agency under either the Program or the Maintenance Gran 20 Program, as applicable, to be originated and serviced b 21 the Contractor as set forth in this Agreement, 22 Each Program Loan under the Program i by Amendment No.1. 23 an Agency-Designated Neighborhood may include a componen 24 which is repayable as a loan by the Qualified Homeowner t 25 the Agency for the structural improvements to the Home an SBEO/0001/DOC/4128-1 7/19/00 915 jmw 5 CDC/2000-24 a component which is a grant for the eligible exterio 2 aesthetic amenities and landscape improvements, if any. I 3 each Maintenance Grant Program transaction the proceeds 0 4 the Program Loan shall be a grant of the Agency to th 5 Qualified Homeowner; provided however that the Qualifie 6 Homeowner under each Maintenance Grant Program transactio 7 shall continue to reside in the Home for at least twelv 8 (12) months following the completion of the indicated Wor 9 in such Home. For the purposes hereof, in a particula 10 instance, a Program Loan to a Qualified Homeowner in a 11 Agency-Designated Neighborhood may thus include a loa 12 and/or an optional grant component under the Program. Th 13 terms and conditions of each Program Loan in an Agency- 14 Designated Neighborhood under the Program are described i 15 the Scope of Services attached as Exhibit "e" to th 16 original agreement, and are more fully set forth in th 17 "EDA Rehabilitation Loan & Grant Policies and Procedures 18 Manual" on file with the Agency. The terms and conditions 19 transaction under of each Program Loan grant 20 Maintenance Grant Program are described in the Scope 0 21 Services (Maintenance Grant Program) attached hereto 22 Exhibit "0" and approved as part of Amendment No. 1 to 23 Agreement. Each Program Loan under either the Program 0 24 the Maintenance Grant Program, as applicable, shall 25 evidenced by the Program Loan Documents." SBEO/000l/DOC/4128-1 7/19/00 915 jrnw 6 2 Section 7. CDC/2000-24 Section 1 of the Agreement is hereby amende 3 to modify the definition of the term "Program Loan Documents" to 4 read as follows: 5 6 " "Program Loan Documents" means and refers collectively to 7 each of the following documents executed by the Qualifie 8 Homeowner: 9 (a) 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 SBEO/0001/DOC/4128-1 7/19/00 915 jmw in the case of a Program Loan in an Agency- Assisted Neighborhood: (i) the Program Loan Application; (ii) the Program Loan Agreement and the customary consumer loan term disclosure documentation; (iii)the promissory note of the Qualified Homeowner payable to the Agency and dated of of initial the date as disbursement of Agency Funds for the account of the Qualified Homeowner to the Program Loan Disbursement Account; (iv) the deed of trust on the Home which secures the repayment of the promissory note to the Agency. The deed of trust also contains certain community redevelopment home affordability 7 2 3 4 5 6 CDC/2000-24 covenants enforceab1e by the Agency; and (v) a po1icy of tit1e insurance in favor of the Agency as 1ender insuring security interest in the deed of trust. The genera1 form of Program Loan Documents 7 its (a) (ii) , (a) (iii) and (a) (iv) for use by the Consu1tant and eac 8 Qua1ified Homeowner in connection with each Program 9 originated in an Agency-Designated Neighborhood are on fi1 10 with the Agency. 11 12 13 14 15 16 17 18 19 20 21 (b) in the case of a Program Loan grant transactio (i.e. : affordab1e sing1e fami1y an maintenance and rehabi1itation grant) under Maintenance Grant Program: (i) the Program Loan App1ication (Maintenanc Grant Program) ; (ii) the Maintenance Grant Program Agreement b and between the Qua1ified Homebuyer and th Agency. The genera1 form of the Program Loan Documents (b) (i) 22 (b) (ii) 23 for use by the Consu1tant and each Homeowner in connection with each Maintenance Grant Progr 24 transaction are on fi1e with the Agency." 25 SBEO/0001/DOC/4128-1 7/19/00 915 jmw 8 Section 8. CDC/2000-24 Section 1 of the Agreement is hereby amende 2 to modify the definition of the term "Qualified Homeowner" to 3 read as follows: 4 5 " "Qual.ified Homeowner" means and refers: 6 (a) 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 (b) 22 23 24 25 SBEO/0001/00C/4128-1 7/19/00 915 jmw in the case of a Program Loan in an Agency- Designated Neighborhood under the Program to person or househol.d which: (i) owns and a singl.e famil.y residential. dwel.l.ing unit ( "Home") as its principal. residence for at l.eas twel.ve (12) continuous months preceding of submission of its Program Loan Appl.ication the Consul.tant; and (ii) has a personal. househol.d income l.evel., adjusted for during the twel.ve (12) months preceding the dat of submission of its Program Loan Appl.ication t the Agency wi thin the ranges of income for and moderate income househol.ds, adjusted famil.y size, as set forth in Exhibit "A" to original. Agreement; and in the case of a Program Loan grant transactio under the Maintenance Grant Program to a perso or househol.d which: (i) owns and occupies singl.e famil.y residential. ( dwel.l.ing unit "Home") as its principal. residence for 9 2 3 4 5 6 7 8 9 10 II 12 13 14 Section 9. CDCj2000-24 twelve (12) continuous months preceding the dat level, of submission of its Program Loan Applicatio (Maintenance Grant Program) to the Consultant; and (ii) has a personal or household adjusted for family size, during twelve (12) months preceding the date submission of its Loan Applicatio Program (Maintenance Grant Program) to the Agency the for income for ranges households, adjusted for family size, as forth in Exhibit "E" attached hereto and as approved by Amendment No.1 to the Agreement." Section 1 of the Agreement is hereby amende 15 to modify the definition of the term "Services" to read as 16 follows: 17 18 " "Services" means and refers to: 19 (a) 20 21 22 23 24 25 SBEO/0001/DOC/4128-1 7/19/00 915 jrnw in the case of implementation in an Agency-Designated Neighborhood, the progr Loan origination, Agency Fund disbursemen control and related accounting and Work monito (course of construction builder services to be provided by the Agency. The various elements of such Services 10 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Section 10. CDC/2000-24 for a Program Loan in an Agency-Designate "c" to the original Agreement; Neighborhood are more fully set forth in "Scope of Services" attached hereto as Exhibi (b) in the case of implementation of a Program Loa grant transaction under the Maintenance Program, the Program Loan origination, Fund disbursement control and related accountin and Work monitor (course of construction builde contract) services be provided by to Consul tan t to the Agency. The various of such Services for a Program Loan transaction under the Maintenance Grant progr are more fully set forth in the "Scope Services (Maintenance Grant Program)" hereto Exhibit and as "D" approved as Amendment No. 1 to the Agreement. The first paragraph of Section 3 of the 20 Agreement is hereby amended to read as follows: 21 22 "Section 3. 23 SCOPE OF SERVICES. Consultant agrees provide the Services to the Agency as set forth herein 24 as described in the Scope of Services attached as Exhibi 25 "c" for each Program Loan originated under the Program, an SBEO/0001/DOC/4128-1 7/19/00 915 jrnw 11 CDC/2000-24 to provide the Services to the Agency as set forth herei 2 and as described in the Scope of Services (Maintenanc 3 Grant Program) attached as Exhibit "D" for each progr 4 Loan originated under the Maintenance Grant 5 Promptly following the date of approval of this Agreemen 6 (and as amended by Amendment No. 1 to this Agreement) 7 the governing board of the Agency the Consultant shall..." 8 9 Section 11. Section 5 of the Agreement is hereby amende 10 to read as follows: 11 12 "Section 5. This Agreement TERM OF AGREEMENT. 13 take effect upon approval by the governing board of 14 Agency and the complete execution by the parties. 15 Agreement, as amended by Amendment No. 1 shall remain i 16 effect through September 30, 2001. Upon mutual 17 agreement of the parties in their sole and separat 18 discretion, dated on or before August 1, 2001, 19 Agreement may be extended after September 30, 2001, for 20 additional period of time of up to twelve (12) months." 21 22 Section 12. Section 6 of the Agreement is hereby amende 23 to add a new Section 6(d) to read as follows: 24 25 SBEO/000l/DOC/4128-1 7/19/00 915 jmw 12 CDC/2000-24 "(d) This Section 6(d) provides for compensation payable t 2 the Consultant by the Agency for Services performe 3 relating to Program Loan grant transactions originate 4 under the Maintenance Grant Program. The Agency shall 5 compensate Consultant for the performance of Services 6 relating to the origination of each Program Loan gran 7 transaction under the Maintenance Grant Program i 8 accordance with the following schedule: (i) the sum 0 9 $100 for each completed Program Loan Applicatio 10 (Maintenance Program) processed Grant by II th Consultant under the Maintenance Grant Program, plus 12 (H) Fifty Thousand Five Hundred Two 13 ($52,500.00), payable in twelve (12) equal 14 installments of $4,375.00 each. The amoun t 15 compensation payable to the Consultant for Progr 16 transaction originated under Loan grant 17 Maintenance Grant Program is consistent with 18 Agency's Mobile Home Handy Worker Grant progr 19 administered by the Consultant on behalf of 20 Agency. The Consultant shall receive compensation 21 Program Loan grant transactions originated under 22 Maintenance Grant Program as provided in 23 and (c) with the first such installment payable fo 24 the Maintenance Grant Program component as 25 Dollars Amendment No. 1 to the Agreement with thirty (30) days SBEO/0001/DOC/4128-1 7/19/00 915 jmw 13 CDC/2000-24 following the date of approval of Amendment No. 1 b 2 the governing board of the Agency." 3 4 Section 13. The Agreement is hereby amended by adding 5 each of the following exhibits thereto which related to the 6 Citywide Program and Program Loans which may be originate 7 pursuant to the provisions of Amendment No.1 to the Agreement: 8 9 (Maintenance Exhibit "D" Scope of Services 10 Program) 11 Exhibit "E" Maintenance Grant Program progr 12 Loan/Grant Househol Application and 13 Income Limitations 14 15 This Amendment No. 1 shall take effect Section 14. 16 following its approval by the governing board of the Agency when 17 it has been fully executed by the authorized officers of the 18 parties. 19 20 21 22 23 24 25 SBE010001/DOC/4128-1 7/19/00 915 jmw 14 CDC/2000-24 IN WITNESS WHEREOF, the parties have caused this Amendment 2 No. 1 to the Agreement to be executed as of the day and year 3 first written above. 4 AGENCY 5 Redevelopment Agency City of San Bernardino 6 7 8 9 10 Approved as to Form: 11 J . h..u... 1- .:; l- ~ Agency,counsel ~ CONSULTANT 12 13 14 Neighborhood Housing Services of the Inland Empire, a California non-profit corporation 15 16 D~I~ ~~!!:!r Executive Director 17 18 19 20 21 22 23 24 25 SBEO/0001/DOC/4128-1 7/19/00 915 jrnw 15 CDC/2000-24 "EXHIBIT D" SCOPE OF SERVICES MAINTENANCE GRANT PROGRAM The Consultant shall implement, administer and oversee the Single Family Maintenance Grant Program. This Grant Program shall be offered to Qualified Homeowners, who are in need of general home repairs which include but are not limited to: Roof replacement, exterior painting, landscaping (automatic sprinklers and grass seed), plumbing, flooring, heating and air system replacements, electrical work, sewer repair or sewer installation, termite repairs, exterior concrete flatwork (such as sidewalks, driveways, curbs, gutters), hand railings, doors, window screens or replacement, tub/shower and toilet repairs or replacement, repair foundation or structural deficiencies, etc. The Maximum Grant Amount the Consultant can expend per Qualified Homeowner and dwelling unit is $5,000. This Grant may be available to a Qualified Homeowner not more than once every five (5) years. This is a Grant to be provided to the Qualified Homeowner and requires no repayment or encumbrance on the real estate. The Consultant shall process Grant Applications on a first come, first serve basis. However, in case of emergency, or life threatening situations, the Consultant may process an application on an urgent basis subject to approval by the Agency Executive Director. The Consultant shall first utilize and exhaust the existing waiting list and continue to add applicants to the list. However, the Consultant shall also offer assistance to Qualified Homeowners who are on the waiting list provided by the Agency from the West Side Community Development Corporation (WSCDC). Upon Consultant determining that the Qualified Homeowner is eligible to participate in the Grant Program, the Consultant will insure that all work performed on the Qualified Homeowner's place of residence are performed by State Licensed Contractors. The Consultant shall be required, whenever feasible, to obtain a minimum of three (3) bids for all work performed. All work performed by Contractors, shall be completed within 45 days from commencement date. From time to time, the Agency and Consultant shall coordinate inspection site visits to insure that the work being performed on a Qualified Homeowners place of residence is being performed in a good workman like manner and in accordance with applicable codes (UBC, UPC, UMC, NEC and health & safety) and City Ordinances. The Consultant shall also require that any Contractor performing work under the Grant Program is licensed to perform business in the City of San Bernardino and has a current license with the State of California Contractor's License Board. P:\Fonns\Housing Forms\Housing Misc\Exhibit D Maint. Grant Program.doc CDC/2000-24 APPLICANT ELIGIBILITY REQUIREMENTS 1. "Qualified Homeowner" must be an owner occupant for a minimum period of one (1) year; on a case-by-case basis, and depending on the circumstances, this requirement may be waived by the Executive Director of the Agency or his/her designee; Applicant must provide evidence of ownership and length of residency. 2. Qualified Homeowner must complete a Grant Application (see Exhibit "E") and meet the applicable income criteria. The applicant's annual income shall not exceed 80% of the median income for San Bernardino County. The Agency shall provide the Consultant with the income limits for each program year. Consultant will use an application for the Grant Program similar to Exhibit "E" attached hereto. 3. All Qualified Homeowner's must agree to sign a maintenance covenant and agree to live in their home for not less than one (1) year following completion of the work performed under the Grant Program. The Consultant shall maintain accurate records for inspection by the Agency concerning income and program occupancy of all persons obtaining assistances from the Consultant pursuant to this Agreement. Consultant shall also provide quarterly reports to the Agency. P:\Fonns\Housing Forms\Housing Misc\Exhibit D Maint. Grant Program. doc CDC/2000-24 City of San Bernardino - Redevelopment Agency , MAINTENANCE GRANT PROGRAM APPLICATION NEIGHBORHOOD HOUSING HOUSING SERVICES, INC. (NHS) Social Security Number Applicant's Name (Last, First, MI) Applicant's Name (Last, First, MI) Applicant's Date of Birth Street Address Applicant's Phone Number San Bernardino City/Zip Years at Residence: Household Size: Number of Minor Children (If Applicable): _ Head of Household: 0 Male 0 Female II r . d h h If List a persons Ivmq in resi ence ot er t an yourse : Name Relationship Age Social Security # Employed Yes No All income of all household occu ants must be shown here. $ $ $ Child Su ort $ TOTAL MONTHLY INCOME: $ $ s $ $ TOTAL ANNUAL INCOME: $ 8+ 50050 Ethnicity: (Please check all that apply) D Sr. Citizen(s) - 62 or Older D Black D American Indian D Female Head of Household D Hispanic D White D Disabled One or More D Other D Asian or Pacific Islander I certify under penalty of perjury that the information provided above is correct to the best of my knowledge. I understand that the inclusion of any willful misrepresentation on this form constitutes ground for rejection of this application and recapture of any financial benefit I may have received. I authorize the NHS to examine and verify any and all information provided in this application. Date: Signature Date: Signature P:\Forms\Housing Forms\Housing Misc\Application-Oldtimers.doc -07/07/00 ATTACHMENT "E"