CHN Housing Partners LEAD Safe Home Program Application

Page 1 - Welcome

Welcome to CHN Housing Partners Online Application for LEAD Safe Home Program 

Need help making your property lead safe? We are here to help! 
On behalf of the Lead Safe Cleveland Coalition, CHN Housing Partners is offering loans, grants, and incentives to homeowners (landlords and owner occupants) to help make their property lead safe. Once approved and awarded funding, CHN Housing Partners will manage the lead construction project. 

TYPES OF ASSISTANCE: 
▪ Loans 
▪ Grants 
▪ Clearance Incentives

Who is eligible to receive lead funding?
Homeowners (landlords and owner occupants) in the City of Cleveland who meet these minimum eligibility guidelines which include, but are not limited to: 

▪ Property must be built before 1978 and located in the City of Cleveland
▪ Owner must be current on all property taxes or have a payment plan in place
▪ If this is a rental property: Owner must have current rental registration issued by the City of Cleveland Department of Building and Housing

                      Income guidelines for Grants are outlined below: 
                                                                     
                                                Income Guidelines
                                                                                          
                    
Income guidelines                                                                                                                                                                                                 
 

To determine program eligibility, complete the program application and submit requested documents. You will be asked to provide copies of the following via upload at the end of this application: 

1. Photo identification for each household member over 18 years of age.
2. Proof of Homeowner Income – all individuals in the household 18 years or older must provide 30 days proof of income and last 2 years of Federal tax returns. You may provide check stubs or current benefits award letter. 
3. Proof of Tenant Income (if applicable)- all individuals in the household 18 years or older must provide 30 days proof of income. You may provide check stubs or current benefits award letter. 
4. Current City of Cleveland Rental Registration for property (if applicable)
5. Lease Agreement (if applicable)

For your convenience, CHN Housing Partners allows the use of e-signatures with this online form. You will be prompted to enter your name at the end of this form prior to submitting to give consent. If you have questions or need further assistance, please call our hotline at 844-614-LEAD (5323)
.
Online Application Guidelines
To apply for programs with CHN Housing Partners, you must complete an application with us, along with providing documents to verify the information submitted. Each participant in this program is required to provide their annual income level and establish eligibility for this program and to verify race/ethnicity for data collection purposes only. We have split this into the following sections:

1. Homeowner information: Your contact and demographic information
2. Homeowner household members : Other members of your household and their demographic information
3. Income sources: All sources of income and public benefits for all Homeowner household members over 18
4. Property or Unit Information: Details about your property that you wish to make lead safe. 
5. Tenant household members (if applicable): All tenant household members and their demographic information
6. Tenant Income (if requested): All sources of income for household members over 18 that reside in the property
7. Upload Documents: We will request scanned copies, legible photos or screenshots of documents as verification for your eligibility for programs. 

You may encounter a slow system or downtime due to a high volume of traffic on the site. Please use the "Save my progress and resume later" feature located at the top of the form OFTEN to avoid losing any information. (This form is powered by FormAssembly.)



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Page 2

Prequalification Questions





Please proceed with your application

Based upon your responses, you do not meet the minimum qualifications for this program

Page 2 - Applicant and Co-Applicant Details

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Applicant and Co-Applicant Details

In this section, please enter your most up to date contact information and demographic information.

CHN Housing Partners (CHN) is committed to assuring the privacy of individuals and/or families who have contacted us for assistance. We realize that the concerns you bring to us are highly personal in nature. We assure you that all personal information shared verbally and/or in writing will be managed within ethical and legal consideration. Additionally, we want you to understand how we use the personal information we collect. Please carefully review this notice as it describes our policy regarding the collection and disclosure of your nonpublic, personal information.
 
CHN's Privacy Policy

The Applicant (and Co-Applicant, if applicable) should be an adult member of your household that will be able to represent, provide information for, and make decisions on behalf of your household. 


Please prepare for upload: Photo Identification and Social Security Cards for each Applicant and Co-Applicant.
Applicant Information







A valid applicant Social Security Number must be entered. Entries such as "000-00-000" or
"111-11-1111" or similar invalid entries will not be accepted.










Enter date in MM/DD/YYYY format










Please select the Agency that helped you complete this Application or made you aware of it

If you are, you do not have a separate business entity for your property ownership business and receive payments using your social security number
PLEASE PREPARE FOR UPLOAD: Completed & Signed IRS form W-9
Property Owner Entity Information








Need help? Call out hotline at 844-614-LEAD (5323)


WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.


Page 3 - Household Members

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Household Members

Please enter additional members who reside in your household (i.e. children, dependents, other family members, etc.). Use the "Add Additional Household Member" link to add as many as you need.

You do not need to re-enter Applicant information here.


Please prepare for upload: For each household member, be prepared to provide verification that they are your dependents - such as Social Security Cards and Birth certificates


Household Member


Enter date in MM/DD/YYYY format











Need help? Call our hotline at 844-614-LEAD (5323)

WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.

Page 4 - Income Sources

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Current Income Sources and Public Benefits


Please enter all sources of Income and Public Benefits that your household is CURRENTLY receiving, for all household members over the age of 18. 


Use the "Add Additional Income Source" link to add as many as you need


Current Annual Income is the estimated income for the current year including any wages,

benefits, alimony, child support and other forms of financial income or support.


Income includes: Full-time employment, part-time employment, self-employment, spousal support, child support, investment income, Social security, SSI, SSDI, income from assets, pension/annuity, unemployment, adoption subsidy, short term disability, long term disability, veteran's benefits, zero income, family contribution, other

Public benefits include: Food stamps, WIC, ADC, OWF/TANF, rental subsidy, utility allowance, other public benefit

Please prepare for upload: Verification of income for the past 30 days - pay stubs, employment letters, award letters, etc. You may also use this Self Certification of Income Form in lieu of Income Documents.

Current Income or Public Benefit Source

Enter the Household Member who this income belongs to


Provide the Job Title for Employment types, if applicable
Please take the total income you received in the last 30 days and multiply by 12 to determine your annual income:

Please estimate to the best of your ability. Our staff will review your documents and provide a full eligibility determination.
Need help? Call our hotline at 844-614-LEAD (5323)

WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.

Page 5 - Unit Details

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Unit Details

We will be asking more specific questions about your subject property here.

You must submit one application for each unit you would like evaluated.

Please prepared for upload: Lease Agreement (if applicable)
Unit Details























Need help? Call our hotline at 844-614-LEAD (5323)

WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.

Page 6 - Tenant Household

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Tenant Household Members

Please enter members who reside in your household (i.e. children, dependents, other family members, etc.). Use the "Add Additional Household Member" link to add as many as you need.



Household Member


Enter date in MM/DD/YYYY format











Need help? Call our hotline at 844-614-LEAD (5323)

WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.

Page 7 - Tenant Income Sources

Flow

TENANT HOUSEHOLD Income Sources and Public Benefits


Please enter all sources of Income and Public Benefits that the TENANT household is CURRENTLY receiving, for all household members over the age of 18. 


Use the "Add Additional Income Source" link to add as many as you need


Current Annual Income is the estimated income for the current year including any wages, benefits, alimony, child support and other forms of financial income or support.


Income includes: Full-time employment, part-time employment, self-employment, spousal support, child support, investment income, Social security, SSI, SSDI, income from assets, pension/annuity, unemployment, adoption subsidy, short term disability, long term disability, veteran's benefits, zero income, family contribution, other

Public benefits include: Food stamps, WIC, ADC, OWF/TANF, rental subsidy, utility allowance, other public benefit

Please prepare for upload: Verification of income for the past 30 days - pay stubs, employment letters, award letters, etc. You may also use this Self Certification of Income Form in lieu of Income Documents.

Current Tenant Income or Public Benefit Source

Enter the Household Member who this income belongs to


Provide the Job Title for Employment types, if applicable
Please take the total income you received in the last 30 days and multiply by 12 to determine your annual income:

Please estimate to the best of your ability. Our staff will review your documents and provide a full eligibility determination.
Need help? Call our hotline at 844-614-LEAD (5323)

WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.

Page 8 - File Upload

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Upload Documents

Please use this page to upload documents that support your application. You can attach electronically downloaded documents, use a scanner, or take pictures or screenshots of your documents with your phone.

You can upload multiple files per section by using the "Add another ..." link. There is a limitation of 20 files per form. If you have more than 20 files to upload, please email them to Lead@chnhousingpartners.org

Gather the required documents:
1. Photo identification for each household member over 18 years of age.
2. Proof of Homeowner Income – all individuals in the household 18 years or older must provide 30 days proof of income. You may provide check stubs or current benefits award letter. 
3. Proof of Tenant Income (if requested)- all individuals in the household 18 years or older must provide 30 days proof of income. You may provide check stubs or current benefits award letter. 
4. Current City of Cleveland Rental Registration for property/ Unit (if applicable)
5. Lease Agreement (if applicable)

Complete applications with all required supporting documents will be processed faster - please upload as much as you are able to and ensure you have documents for each section!  

Landlord Documents






Tenant Documents (if applicable)





Need help? Call out hotline at 844-614-LEAD (5323)

WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.

Page 9 - Acknowledgement

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Acknowledgement & Submit

Lead Services Program

Terms of Service

 

Before Lead services can be provided, a trained and program-certified inspector under contract or direct employment with CHN will visit your home to determine what lead services are needed to make your home lead safe. The inspection process may take a few hours and the inspector must have clear access to the attic, living spaces and basement.

 

Please take note that if the inspection reveals unsafe conditions that lead work cannot be completed until all unsafe conditions are resolved and corrected.

 

The amount of grant funding awarded is based on the current 120% AMI (area median income). If the total project costs exceed the funding awarded amount then additional funds will need to be provided by the applicant in order to complete the project.

 

Once approved funding has been awarded, your project will be assigned an initial inspector. After the inspection, the inspector will explain to you the work that needs to be done, will complete paperwork, and the lead services team will contact the contractor(s) that will be doing the work on your home. The contractor will then contact you regarding the job schedule for your lead services work. Upon completion, an inspector will come back to your home to make sure that the work was done correctly and to perform a final clearance inspection. Following a passed clearance inspection, it is the responsibility of the property owner to obtain their Lead Certificate from the City of Cleveland.

 

By my signature below, I have read and ACCEPTED the above terms and services provided by CHN Housing Partners’ lead services department. I acknowledge that I have provided correct and factual information, to the best of my knowledge.  I understand and acknowledge that CHN Housing Partners and its contractors will provide services to my property and CHN Housing Partners will pay the contractors directly. I acknowledge that I, the applicant, am the owner of the property and/or the property manager of the property.

I/we certify that all provided information is correct to the best of my knowledge and have received a copy of CHN's Privacy Policy. I/we authorize CHN Housing Partners to verify all information contained on this online form and to pull my credit report. I/we understand that I may be assisted by federal funds which carry severe penalties, including incarceration.

By typing my full name below, I hereby authorize CHN to release nonpublic personal information it obtains about me to any third parties necessary to provide me with the services I requested. I acknowledge that I have read and understand the above privacy practices. I understand I will receive a copy of all information submitted at the email address I provided on Page 2, "Applicant E-mail Address".
WARNING: The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government.



If you are applying for additional units, please submit this complete application. You will receive a follow-up email with instructions on how to submit the additional unit and tenant info.