HAF Assistance Request Form

HAF Assistance Request Form

WHEREAS

WHEREAS, Applicant Name: seeks financial assistance under the Homeowner Assistance Fund (HAF) for eligible housing-related expenses; and

WHEREAS, Provider / Agency Name: administers HAF resources and will evaluate and, if approved, disburse assistance in accordance with program policies and the terms set forth in this request; and

WHEREAS, the parties desire to document the Applicant's request, the proposed scope of assistance, and the standard terms governing any approved disbursement.

APPLICANT INFORMATION

PROPERTY INFORMATION

Property Type: Single-Family Multi-Family Condominium

ASSISTANCE REQUEST / SCOPE OF ASSISTANCE

Describe the assistance requested, circumstances necessitating assistance, and any immediate actions required.

Assistance Purpose (select all that apply): Mortgage Assistance Rent Arrears Utilities Other

PAYMENT TERMS (IF APPROVED)

Assistance Amount Authorized:

Late Fee Policy (applies to repayment or applicant obligations where permitted):

TERM AND TERMINATION

Term Start Date: Term End Date:

Either party may terminate any approved disbursement obligation for material noncompliance upon written notice to the other party. Notice period required prior to termination:

CONFIDENTIALITY

Applicant information and documentation submitted in support of this request will be treated as confidential and used solely for eligibility determination and administration of HAF benefits, except as disclosure is required by law or necessary to effect payment. Provider shall maintain reasonable safeguards to protect nonpublic personal information provided by Applicant.

CERTIFICATIONS AND AUTHORIZATIONS

By checking the boxes below and signing this form, Applicant certifies under penalty of perjury that the information provided is true and accurate to the best of Applicant's knowledge and authorizes Provider to verify income, household composition, and other eligibility criteria with third parties as reasonably necessary to process this request.

I certify the information is true and correct.

I authorize verification of income, residency, and indebtedness as needed.

GOVERNING LAW; ENTIRE AGREEMENT

This request and any resulting disbursement obligations shall be governed by the laws of the state where the property is located, without regard to conflict of law principles. This form, together with any separate approval notice or disbursement agreement executed by the parties, constitutes the entire understanding between Provider and Applicant with respect to the requested assistance and supersedes all prior representations and agreements, whether written or oral.

ADDITIONAL INFORMATION

Program Effective Date (if applicable):

Applicant Acknowledgement: I acknowledge that submission of this request does not guarantee approval and that additional documentation may be requested.

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