PIMA COUNCIL ON AGING 2007-2008

MAJOR AND MINOR HOME REPAIR AND ADAPTATION APPLICATION

(PLEASE CHECK OR FILL IN - ATTACH ADDITIONAL INFORMATION IF NECESSARY)

A: HOUSEHOLDER INFORMATION

Print name of taxpayer (1) __________________________________________Date of Birth: ____________

(Owner/occupant/applicant)

Print name of taxpayer (2) __________________________________________Date of Birth: ____________

(Owner/occupant/applicant)

Print name & address of alternate contact (3) __________________________________________________

Address of home: _ Zip Code: ______________

Mailing address (if different from home):________________________________Zip Code: ______________

Phone Number (1) _____________________________Phone number (3) ____________________________

Signature of applicant (1) Date:____________________

Signature of applicant (2) Date: ____________________

Your signature certifies that all information on this application is true and correct to the best of your knowledge and belief. (If you are selected, program staff will verify all information in person).

1. YES☐ NO☐ The taxpayer(s)/homeowner(s) is/are or will be age 60 or over by June 30, 2007.

(If “NO” stop here, you are NOT eligible.)

2. YES☐ NO☐ I own, or am buying, the home I live in. (If “NO” stop here, renters are NOT eligible.)

3. YES☐ NO☐ I have unsuccessfully applied for this program in the past. If ”YES”, how many times? _____

4. YES☐ NO☐ I, or members of my household, have severe physical disabilities or chronic diseases that interfere with our ability to care for ourselves. Please list all medical conditions that can be verified by a doctor: (DO NOT send medical records, if you are selected, this information will be verified in person.)

5. YES ☐ NO ☐ Dependents live with me. (DO NOT list your spouse) If “YES”, HOW MANY?_______

6. Name: _______________________________ Age:___________Relationship: ___________________

7. Name:________________________________Age:___________Relationship: ___________________

8. Name: Age: Relationship:

B: HOME or MOBILE HOME INFORMATION (VALUATION MUST BE UNDER $125,000)

1. My home is: (☐ Condo/Townhouse) (☐ House) (☐ Mobile Home - size: _____by______) (☐ RV)

2. YES ☐ NO ☐ My home is within the Tucson City limits.

3. YES ☐ NO ☐ I own other real estate. (If “YES”, attach a description with address and valuation)

4. What is the approximate age of your home? __________ Year built _______________

5. How long have you lived in this home? __________ Years

6. What is the full cash value of your home or mobile home based on your tax statement? _____________

(You must attach a copy of your Mobile Home Valuation statement if you have a mobile home)

7. How many bedrooms are in your home? _________

8. How many bathrooms are in your home? ____________

9. What is your monthly mortgage payment? _____________

10. Is your home paid for free and clear? _____________

11. Would you consider a loan against your home equity to pay for necessary repairs? ___________

12. Would you accept minor repairs worth up to $750 if you are NOT selected for major? _________

NAME: _______________________________ PAGE 2 OF 3

C: HOUSEHOLD INCOME INFORMATION

TOTAL MONTHLY INCOME (If you are selected, financial records will be verified in person)

LIST INCOME OF SOCIAL SECURITY, SSI, DATE OF ALL HOUSEHOLD DISABILITY, PENSIONS, FULL-TIME PART-TIME

BIRTH MEMBERS RENTALS, ETC. EMPLOYMENT EMPLOYMENT Head Of

____________ Household $ ___________________ $ $ ________________

____________ Spouse $ ___________________ $ $ ________________

____________ Other $ ___________________ $ $ ________________

____________ Other $ ___________________ $ $ ________________

____________ Other $ ___________________ $_______________ $ ________________

MONTHLY TOTALS: $ ___________________ $ $ ________________

________________________________________________________________________________

CASH ASSETS OF ALL HOUSEHOLD MEMBERS: TOTAL: $________________

Current balances in ALL household accounts for ALL household members: Checking, Savings, CD's, IRAs, Stocks, Bonds, etc (If you are selected, this information will be verified in person).

HOME REPAIR OR MODIFICATION DESCRIPTION

Please describe your repair and/or disability modification need in great detail, the more information you provide, the greater your chances of being selected. Please number your three (3) most important repair needs first. Priority is given to correct health and safety hazards. You may attach additional pages if you need more space to describe your situation. There is no guarantee that photos will be returned. If you have questions or need assistance in describing your repair or modification needs, call the Pima Council on Aging, 790-0504 extension 2016

#____ ROOFING SYSTEM: Includes replacement of leaking roof; decking, fascia, rafters or joists; cooler jacks and stands, vents, ductwork, scuppers, skylights, etc: Describe your roof by age, type, size, where it is leaking, for how long it has been leaking and any resulting damage.

#____ PLUMBING SYSTEM: Includes repair or replacement of leaking gas and/or water lines between house and meter; clogged or broken sewer or septic tank; broken hot water heaters; kitchen or bathroom drains; leaks in kitchen or bathroom fixtures; leaks in hot water heater or evaporative cooler. etc. Describe age and type of pipes, where leaks are located, where clogs are located, if gas or water is disconnected by utility, how long it has been leaking or clogged and any resulting damage.

#____ ELECTRICAL SYSTEM: Includes upgrade to minimum 100 amp circuit; weather head and service drop; dedicated electrical circuits for modern appliances; repair or replacement of dangerous wiring, installation of ground fault receptacles in kitchen and bathroom; smoke alarms in hall and bedroom areas, repair of switches, outlets, etc. Describe the age of your system, what is not working and where it is not working and if electricity is disconnected in any portion of the home.

NAME: __________________________________ PAGE 3 OF 3

#____ STRUCTURAL SYSTEM: Includes broken walls, floors, ceilings; broken windows, exterior doors, window and door frames; termite damage, etc. Describe what is damaged, type of damage, how long it has been damaged, how this is a safety hazard.

#____ DISABILITY MODIFICATIONS: Includes grab bars, wheelchair ramps, roll-in-showers, modified doorways, durable medical equipment, etc. Describe the safety hazard and how this need relates to your medical/physical condition.

#____ HEATING AND COOLING SYSTEM: Includes wall heaters, furnaces, evaporative coolers, window a/c units, thermostats, gas lines and valves, water supplies, electrical connections and upgrades, duct work, vent covers, combustion air venting, drywall patching, etc. Describe the age of your unit, what type, how long it has been broken, etc. (Unserviceable refrigeration unit may be replaced with evaporative cooler) If whole house air conditioning is required for medical reasons, homeowner must provide medical documentation and pay for cost over grant amount.

#____ SPECIAL CONDITIONS: All other emergencies threatening the life or health of the occupants not covered above are considered on a case-by-case basis.

________________________________________________________________________________________

THIS IS NOT AN EMERGENCY HOME REPAIR PROGRAM

Cosmetic and general maintenance repairs (painting, plastering, yard cleaning, fences) are not covered. Appliances (stoves, refrigerators, TVs) cannot be purchased. Additions (bedrooms, dens, garages, porches, laundry rooms) cannot be built.

All Major Home Repair applicants will be notified by the City of Tucson in writing by August 31, 2007 if they have or have not been selected.

Applications must be completed and postmarked or returned in person to the Pima Council on Aging by the deadline date of April 14, 2007. No late applications are accepted. E-mail or fax applications are not accepted.

Please feel free to attach any additional information that may be helpful such as estimates, photos, etc. There is no guarantee that photos can be returned. (Please remember to attach a copy of the Pima County Treasurer's annual tax statement for mobile home valuations. PCOA staff will verify valuations of site-built homes via the Pima County Assessor’s web page. You DO NOT need to mail a copy of your property tax statement if you have a site-built home).

MAIL OR DELIVER TO:

PIMA COUNCIL ON AGING, 8467 E. BROADWAY, TUCSON, AZ 85710

ALL 3 PAGES OF THIS APPLICATION MUST BE RETURNED OR POSTMARKED BY

APRIL 14, 2007.

KEEP THIS PAGE FOR YOUR RECORDS

2007-2008 PCOA MAJOR & MINOR HOME REPAIR APPLICATION

The Pima Council on Aging is accepting applications for two home repair programs depending upon the availability of future federal funds. 1) 2007-2008 Major and Minor Home Repair, Adaptation, Renovation Program, funded by the Federal Older Americans Act through the Pima Council on Aging (local match provided by the City of Tucson with General Funds, 2) 2007-2008 CDBG Elderly Home Repair Program funded by Federal Community Development Block Grant dollars through the Housing Rehabilitation Collaborative of Tucson.

WHAT ARE THESE PROGRAMS? They are NOT emergency home repair programs. If selected, repairs are made in the fiscal year starting July 1, 2007 and ending June 30, 2008. The Pima Council on Aging contracts with the City of Tucson to administer Major Home Repairs with grants up to $4,000 for selected homeowners and Community Home Repair Projects of Arizona (CHRPA) for Minor Home Repairs with grants up to $750. These programs provide critically needed repairs and disability modifications to correct major and minor health and safety hazards for older homeowners.

In no cases may costs exceed the $4,000 limit for Major Repairs and $750 for Minor Repairs. If repairs are estimated to cost more than available grants, homeowners may choose to pay the difference or scale back the proposed work. Some repairs may be provided on a cost-share basis depending upon the income and assets of applicants. Of course, donations can be made to off-set costs.

If selected for Major Home Repairs with the $4,000 grant limit, a lien, in the grant amount only, is placed upon the property for two full years. If the property must transfer before two years, the pro-rated repair amount is due back to the program upon close of sale.

Homes must be located within Pima County, Arizona, on non-tribal lands. Only health and safety hazards are corrected. Cosmetic and general maintenance work such as painting, plastering, yard cleaning, etc, are NOT covered but may be referred to other community based volunteer programs. Household appliances such as stoves and refrigerators CANNOT be repaired or replaced.

City of Tucson staff make all inspections and arrangements to hire private, licensed and registered contractors who provide both the material and labor to complete Major Home Repairs. CHRPA staff make all arrangements and provide the material and labor to complete Minor Home Repairs.

WHO IS ELIGIBLE? Taxpayer/homeowner or spouse must be age 60 or older by June 30, 2007. Persons under age 60, even if disabled, are NOT eligible. Persons assisted with a City/PCOA grant in the past are NOT eligible again. Renters are NOT eligible. The 2006-07 valuation of the property must be under $125,000. If there are questions about ownership, equity rights under contract, life estate to the property, etc. please call PCOA at 790-0504 for clarification. Funds are extremely limited. Selection is based upon greatest economic and social need with priority given to those individuals who have nowhere else to turn for assistance and who are caregivers for others. Applications are prioritized by a Committee of the PCOA Advisory Council composed of community volunteers who do not see names or addresses of applicants.

HOW TO APPLY? Applications in English and Spanish are available from the Pima Council on Aging by mail or at the address below. Applications must be completed and returned IN PERSON OR BY U.S. MAIL to the Pima Council on Aging BY THE DEADLINE DATE OF APRIL 14, 2007. No e-mail or fax applications are accepted. No late applications are accepted, no exceptions.

Applicants for the $4,000 Major Home Repair grant will be notified by the City of Tucson in writing by August 31, 2007 if they have or have not been selected. Call 790-0504, ext 2016 if you need telephone assistance in completing the application (English or Spanish).

PIMA COUNCIL ON AGING 8467 EAST BROADWAY, TUCSON, ARIZONA 85710

Phone (520) 790-0504 ext 2016

E-mail: dedwards@pcoa.org