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Housing Rehabilitation Loan

Please review the income chart below. To be eligible for the program, the current gross income for all household members over the age of 15 must be below the limit for the size of the household. If you think you are income-eligible, complete and submit this form.We will review it and, if you appear to meet the basic criteria, we will add your name to the waiting list.

Household Size
1
2
3
4
5
6
7
8
Annual Income 40,900 46,750 52,600 58,400 63,100 67,750 72,450 77,100
Monthly Income  3,408  3,896  4,383  4,867  5,258  5,646  6,038  6,425
Name
Address
City , Oregon ZIP Code
Phone Email
1. Do you live in Clackamas County? Yes No
2. Do you currently live in the home that you want to repair? Yes No
3. How many people live in your house?
4. What is the total current monthly gross income for ALL persons living in the home over age 15? $
5. Please indicate the sources of your income. Check ALL that apply:
    Earned Income (salaries, wages, commissions, fees, tips, bonuses, etc.)
    Business income
    Interest or dividends
    Income from real estate or from personal property (e.g. rental property)
    Social Security
    Annuities
    Insurance policies
    Retirement funds
    Disability or death benefits
    Unemployment benefits
    Disability compensation or workers compensation
    Welfare assistance, such as TANF (Food Stamps do not count)
    Alimony
    Child support
    Any other regular contribution or gift from an organization or person
    Other
6. Do you file federal income tax returns? Yes No
7. Whose name(s) appear on the title to the property?
8. Type of dwelling? House Duplex Manufactured home on land
(Manufactured homes in parks do not qualify for the Housing Rehab Loan Program.)
9. What year was the house built?
10. How are you purchasing the property? Mortgage Contract N/A - Own free and clear
   If you are purchasing on a contract, is the seller willing to sign a consent to lien? Yes No
11. What is the total County assessed Real Market Value? $
12. What is the balance of the loan? $
13. Is there a second mortgage or line of credit? Yes No
   If yes, amount and source:
14. Are there any other liens against your property? Yes No
   If yes, amount and who:
15. Are the property taxes paid? Yes No Deferred
16. Do you have homeowners insurance on this home? Yes No
17. Check all areas in your home that need repair:
Roof
Gutters/Downspouts
Windows
Furnace/Heat System
Exterior Stairs/Porches
Bathroom
Water System
Doors
Insulation/Weatherization		 Septic/Sewer
Kitchen
Siding
Foundation
Chimney
Exterior Paint
Interior Paint
Other
18. Check every statement that describes your home's current condition:
    There is no working heat source.
    There is no working water system.
    The roof is actively leaking.
    There is no working septic/sewer
19. Would you like your application packet e-mailed or mailed?
    Email US Postal Mail
20. Please tell us how you heard about the program. Check ALL that apply:
    County web site
    County or city newsletter
    Brochure
    Family, friend or neighbor
    Other
21. This inquiry was completed by:  Potential applicant  Someone else
If this inquiry was completed by someone other than the potential applicant, please provide your name, email address or phone number and indicate your connection to the applicant
Name:
Organization:
Email Address:
Phone number:
Relationship/connection to potential applicant:
22. Comments: