BUREAU OF HOUSING
Department of Building and Housing Development
10 N. Second St. Suite 206
Harrisburg, PA 17101
PH: 717-255-6419
Fax: 717-255-6421
www.harrisburgpa.gov

										PID#: 					

APPLICATION FOR ASSISTANCE/PERSONAL DECLARATION
THIS FORM MUST BE COMPLETED IN FULL AND SIGNED BY ALL ADULTS

Please complete this form in your own handwriting. 
•	Use the correct legal name for each member of your household as it appears on their Social Security Card. 
•	All adult members of the household must sign below to certify the information pertaining to them. 
•	For this program, the head of household simply refers to the person in whose name the assistance is provided. Thank you for your cooperation.

PLEASE PRINT AND COMPLETE FORM IN INK
NOTICE: This application MUST be completed by the property owner

I.	HOMEOWNER PROGRAMS
Please check which program you are applying for:
 	 Home Improvement Program (HIP)
 	 Housing Rehabilitation Program

II.	HOUSEHOLD COMPOSITION
Complete for all persons who will be living in your home listing the head of household FIRST. Please provide your contact information below.  The address listed should be the address requesting program funds.

	Name of Applicant

	Address		City	State	Zip

	Home/Cell #	E-mail Address
*Race/Ethnicity: White, Black, American Indian/Alaskan Native, Asian or Pacific Islander, Hispanic/Latino, Other

ADULTS (Legal Name)
First, MI, Last	Sex (M/F)	Date of Birth	Age	Social Security Number	Relation to Head	Place of Birth 
(City/State)	*Race	
					HEAD			

								

CHILDREN (Legal Name)
First, MI, Last	Sex (M/F)	Date of Birth	Age	Social Security Number	Relation to Head	Place of Birth 
(City/State)	*Race	

								

NOTE: You are not required to answer whether a family member has a disability. However, it may help us to identify suitable housing.
1.	Is anyone in your household elderly, or a person with a disability?		 YES	 NO
2.	Does anyone receive disability assistance?				 YES	 NO
3.	Is there any specific accommodation you would like to request?		 YES	 NO
If yes, please explain: 												
4.	Do you have any outstanding medical bills?				 YES	 NO
5.	Is anyone in your household (18 or older) a full-time student?		 YES	 NO
If yes, please list names: 												
III.	TOTAL HOUSEHOLD INCOME
Please list below all money earned or received by everyone living in your household.

Name of Person Receiving Income	Name/Address of Employer or Self- Employment Information	Gross Weekly Wages or Self- Employment Income	Monthly Child Support	Monthly Social Security or SSI Benefits or Pensions	Weekly Unemployment Benefits	

						

						

1.	Do you have any other income not listed above?				YES	NO	
If yes, please list amount and type: 											
2.	Do you or anyone in your household have a checking and/or savings account?	 YES	 NO	 Checking	 Savings
3.	Do you pay child care expenses? 					 YES	 NO	How much? $			
4.	Are you reimbursed for child care?					 YES	 NO	How much? $			
5.	Does anyone help you pay your bills?					 YES	 NO	If yes, please list:			
6.	Is the head of household or spouse a member of the Armed Services?	 YES	 NO	If yes, please list:			
7.	Have you filed for bankruptcy?					 YES	 NO	Discharged or Dismissed?
8.	Are your local real estate taxes and city utilities current?			 YES	 NO
9.	Do you have homeowner’s insurance?					 YES	 NO

IV.	ASSETS
1.	Do any of the family members have or receive income from: (Check all that apply)
 Real Estate	 Company Retirement/Pension Funds	 Insurance Settlements	 Stocks
 Trusts	 Certificate of Deposit			 Bonds			 Other (please list):		
2.	Have you disposed of any assets during the past two years for less than fair market value?	 YES	 NO
If yes, please explain: 												

V.	GENERAL INFORMATION

1.	Have you or any other adult members ever used any name(s) or Social Security number(s) other than the ones currently being used? If so, please list name and social security number(s) used: 						
2.	Have you or anyone in your household been convicted, arrested, charged or evicted from federally assisted housing, including public housing, for any violent, criminal activity in the last three years?			 YES	 NO

If yes, please give names, dates and details of incidents for each occurrence: 																			
3.	Have you or anyone in your household been evicted from federally assisted housing, including public housing, for abuse of alcohol or drug-related activities, which interfered with the health, safety or right to peaceful enjoyment of the premises by other residents in the last three years?						 YES	 NO

If yes, please give names, dates and details for each occurrence: 																					

	Complete the information below listing current monthly household expenses, if any:	
Auto	$	Medical	$	Credit Cards	$	
Furniture	$	Loans	$	Credit Cards	$	
Cable	$	Insurance	$	Other	$	

GRIEVANCE PROCEDURE: The City of Harrisburg’s grievance procedures are designed to provide due process standards and provide for expedient and prompt resolution of complaints related to any type of discrimination. Complaints should be submitted in writing to the Deputy Director of the Department of Building and Housing Development (alternative means of filing a complaint, such as personal interview or tape recording, will be made available for persons with disabilities). The grievance must contain the following:
•	Complainant’s name, address, and phone number.
•	The City activity in which the violation is alleged to have occurred.
•	A complete description of the incident prompting the complaint.
A grievance should be filed by the grievant or his/her designee as soon as possible, but no later than 60 calendar days after the alleged violation.
Within fifteen (15) days of receipt, the Deputy Director will attempt to meet with the grievant to discuss the complaint and the possible resolutions. Within fifteen (15) days of the meeting, the Deputy Director will respond in writing or, where appropriate, in a format accessible to the grievant. The response will explain the position of the City of Harrisburg and a proposed resolution. If the grievant does not agree with the resolution proposed, the grievant or his/her designee may appeal the decision to the Director within fifteen (15) days after receipt of the response. The appeal should include a statement about why the grievant disagrees with the resolution. Within fifteen (15) days after receipt of the appeal, the Director will schedule a meeting with the grievant or designee to gather additional information before issuing the final decision. The Director will issue the final decision within fifteen (15) days of the last scheduled meeting. The decision will be in a format accessible to the grievant.

FAIR HOUSING AND EQUAL OPPORTUNITY: The City of Harrisburg, pursuant to the Harrisburg Human Relations and Discrimination Code, Chapter 4-101, promotes equal opportunity for all persons to participate in the social, cultural, recreational, and economic life of the city and prohibits discrimination in employment, housing, public accommodations, education, and obtaining loans and extensions of credit, free from discrimination because of race, color, religion, ancestry, national origin, place of birth, sex, handicap or disability, or the use of guide or support animals, marital status, familial status, sexual preference/orientation, or age of association with or advocacy on behalf of any group protected by the code.

Please have all family members (18 or older) review the information listed on this form and sign below.
I do hereby attest or affirm that all the information above is true and correct. I understand that any change in source of income, new or additional sources of income and changes to household members must be reported within fourteen (14) days of change. Reporting requires that you provide verification of information to DBHD staff. Thank you!

PLEASE BE SURE YOU HAVE ANSWERED ALL QUESTIONS
Failure to do so may result in the inability to process your application

 	
Signature of Head of Household	Date	Signature of Spouse	Date

 	
Signature of Other Household Adult	Date	Signature of Other Household Adult	Date

Return completed application to:  
City of Harrisburg
Department of Building & Housing Development
10 North 2nd Street, Suite 206
Harrisburg, PA 17101

Warning: Title 18, Section 1001 of the United States code, states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department or agency of the United States.

*** FOR OFFICIAL USE ONLY ***

Property #: 					

Received by: 								Date: 					

Public Accounts:
Taxes (YY): City:		 School: 		 Utility Balance (MM/YY/$):				

Minimum Application Threshold Met:	YES	NO

Age of Home/Estimated Year home Built (if known):