HUD home repair programs
application

A copy of your current Driver’s License, Photo ID, or Tribal ID for all household members 18 and older.*

Proof of ownership of property (e.g. deed, title, or county tax receipt for the current year.)*

If renting: provide your landlord or property manager's information in the next section. They must consent to modifications.*

If you are a legal guardian or have power of attorney for the applicant, and you will be filling out this application for them; please attach appropriate documentation.*

Submit documentation describing all residents of the home plus verification of their income. Download a guided version of this documentation below, and include it with the rest of your document attachments.*

Please attach proof of all household members’ income received. If income is from employment, we will need your most recent 1 month’s (30 days) paycheck stubs. If you are paid through “gig work” (Door Dash, Uber, etc.) we need a monthly report of the income from the app. Eligibility for our income guidelines are based on Gross Income, (before any deductions).*

If you are on a fixed monthly income, we need current proof that you receive that income, for example: SSI and/or Disability Letter, Retirement benefits letter, VA Disability Letter, annuity monthly statement, etc. Originals are preferred.*

For the purposes of these programs, TANF, child support, spousal support, and any other unearned income is considered income. If you are receiving assistance, please attach your original “Notice of Action” sheet for proof. Examples: SNAP Benefits, TANF, Medicaid, or WIC. If you do not have this letter, please provide your case number.*

PLEASE NOTE: we need to verify income for all household members 18 or older. If there is no income in your household, you must include a Zero Income Form.*

Complete and sign the Release of Information.*

If you own your own home, you will need to provide proof of ownership.

If you rent your home, we will need an agreement signed by your landlord and yourself to do any modifications in the dwelling, along with proof they own the property.

By checking this box, I state that I understand this requirement.*

I authorize the agency to make any necessary contacts to verify any aspect of eligibility, including income verification processes.*

I authorize employees of Western SD Community Action agency and/or subgrantees and contractors to perform, monitor and inspect the work that has been done by the agency.*

I authorize staff and/or Occupational Therapists (if needed) to monitor all work to ensure quality control, including any outside contractors that need to be initiated to complete the required work within regulations.*

I agree to report if the home is scheduled for acquisition or clearance by a Federal, State, or Local program within 12 months from the date work is scheduled.*

I understand that any false or misleading statements made in this application are legal grounds for prosecution by any agency of the government using this application as a basis for assistance and certify under penalty of perjury, the information provided in this application is true and correct to the best of my knowledge.*

I agree that all signature lines I have signed on this application or within any documents uploaded with this application are equal to a legal and binding signature, written or otherwise.