North Country Affordable Housing, Inc.
Jefferson, Lewis, & St. Lawrence Counties
Mobile Home Replacement Program
New Home Construction Program

Grant Application

Personal Information
Applicant's Name:   SSN#:
Street Address:    
 
County:
Directions to house: 
Home Phone: Work Phone:
Best place to call:  
How long have you lived there?           years Own or rent?

Household Members
Name Age Employer Social Security Number
       
       
       
       

Household Members Income
Name Income Source Amount Per Week
     
     
     
     

Assets other than house (bank accounts, real property, boat, vehicles, snowmobile, etc.) and value:
 
 
 

Home Information

Do you have a mortgage?

[  ] Yes
[  ] No		 Monthly payment:  
To whom paid:  
Age of mobile home:                 years old
Sewage Disposal:   [  ] Septic Tank
[  ] Public Sewage		  
Water Supply:   [  ] Well
[  ] Public Water
[  ]Other please specify		  
Are sewer and water to your home adequate?  [  ] Yes     [  ] No



Monthly Debts
To whom owed Purpose Amount Owed Monthly Payment
 
 
 
 
 

Have you ever filed bankruptcy? [  ] Yes     [  ] No       
If yes, date finalized: _______________________

Conflict of Interests.
Are you related to: Yes No
Any staff or board member of North Country Affordable Housing?    
A municipal official in the locality where your home is located?    
An employee, immediate family member or staff person to a state or local elected official?    
A leader or chairman of a political party at any jurisdictional level, or an immediate family member of such person?    

All information provided in this application will be kept confidential. All applications received become the property of North Country Affordable Housing, Inc.

Neither North Country Affordable Housing, Inc. nor any other participating agency or financial institution guarantee the quality of the material or workmanship provided under this program. Contractual performance is an obligation of the homeowner.

I (We) hereby apply for financial assistance from the North Country Affordable Mobile Home Replacement Program to replace our mobile home located in Jefferson County. I (We) have read the handbook, and understand the program rules and regulations, including the ten year owner-occupancy requirement. I (We) certify that the above statements are true, accurate, and complete to the best of my (our) knowledge and belief. False statements made knowingly by the applicant will disqualify the applicant from program participation.

I (We) hereby consent to and authorize North Country Affordable Housing, Inc. to: (a) obtain information necessary for administration of the regulations of this program, including credit history, income, expenses, employment, property value, and contractor estimates, and: (b) upon giving reasonable notice, to enter my (our) property to inspect the house during construction and the completed work.
 

signature of applicant   signature of co-applicant  
       
date   date  

Completed applications must be submitted to:
North Country Affordable Housing, Inc., HSBC Bank Building, Basement, 120 Washington Street, Watertown, NY 13601.

Please include a copy of last year’s federal income tax return (with all attachments) with your application, and a copy of your deed.