HURRICANE LOSS MITIGATION PROGRAM (HLMP)
Franklin County, Florida
APPLICATION
This Application is valid for 180 days

DOCUMENTATION REQUIRED WITH APPLICATION
•	Photo ID- Applicant and Co-Applicant
•	Social Security Card- All members of household
•	Home Ownership Paperwork- Property Appraisers, Deed, Mortgage
•	Homeowner Insurance 
•	Income Documentation – Tax Forms, Pay Stubs, Social Security, Disability, Retirement
Applicant/Co-Applicant	Applicant	Co-Applicant	
General Information			
Full Name: 			
Social Security #:
( Last 4 digits only)			
Date of Birth: 		  Age:		  Age:	
Street Address: 		Home Phone: 	
City/State/Zip: 		Cell Phone: 	
Mailing Address: 		Email Address:	
City/State/Zip: 			

Name(s)	Social 
Security #	Date of Birth / Age	Relationship to Applicant	

				
				
  Property Information
Is property your primary residence?           Yes              No          Parcel Number:	
Single Family Dwelling?                               Yes              No          Site Built?     Yes       No           Year Built:	
Existing Liens on Property?                        Yes              No          Title Search May be Performed by Department 	
Note 1: Copy of property deed must be attached to this application.	Property Assessed Value:	
 
    Applicant/Co-Applicant Employment Information:
Employee Name: 	Employer Name: 	
Position: 	Supervisor: 	
Address: 	 Phone:	Time Employed: 	
	Pay Rate:	Pay Frequency: 	
Annual Income (gross salary, overtime, tips, bonuses, etc.): $ 

	
Employee Name: 	Employer Name: 	
Position: 	Supervisor: 	
Address: 	Phone:	Time Employed: 	
	Pay Rate:	Pay Frequency: 	
Annual Income (gross salary, overtime, tips, bonuses, etc.): $ 

	

Other Sources of Income (For ALL Household Members 18 and Over, List Business or Rental Net Income, Child Support, Alimony, Social Security, Pensions, Unemployment or Workers Compensation, Welfare Payments, etc.) 
Name 	Type of Income 	Gross Annual Amount 	
1. 			
2. 			
3. 			
4. 			
		Total: $ 	
        NOTE 2: Attach additional sheets as necessary for all household members 18 years and over.
        NOTE 3: Copy of previous year tax return must be attached with this application.
	
Assets and Asset Income (For ALL Household Members, Including Minors, List Checking and Savings Accounts, IRA, CD, Bonds, Stocks, Equity in Properties, etc.) 
Type of Asset  Checking, Saving, CD  etc.	Name of Bank	Bank/ Account #	Annual Asset Income 	
1. 				
2. 				
3. 				
4. 				
			Total: $ 	

Staff Use Only:
Annual Income: $ ______________   Income Category (VL, LI, MI): ____________ 

Special Needs (For reporting purposes only, please check all that apply for Head of Household Only):  
Disabled _______ Elderly _______ Other ___________________________________________

OTHER INFORMATION	
What type of wind retrofit technique are you interested in? 	

Protection of Opening (Doors/Windows) 
Gable End Bracing
Roof Covering Material	
Roof Deck Attachment
Roof to Wall Connections
Unsure/Need More Information	

Terms, Recapture and Default:  Eligible applicants who qualify for assistance for mitigation assistance will be in the form of a five-year zero-percent deferred payment loan. The five-year deferred loan will be forgiven at a rate of 20% per year.  Sale or transfer of property within the five-year loan term will result in a pro-rated repayment.   Therefore, upon default the balance of the HLMP loan will be immediately due and repayable to Franklin County.

I/we understand that Florida Statute 817 provides that willful false statements or misrepresentation concerning income; asset or liability information relating to financial condition is a misdemeanor of the first degree, punishable by fines and imprisonment provided under Statutes 775.082 or 775.83. I/we further understand that any willful misstatement of information will be grounds for disqualification. I/we certify that the application information provided is true and' complete to the best of my/our knowledge. I/we consent to the disclosure of information for the purpose of income verification related to making a determination of my/our eligibility for program assistance. I/we agree to provide any documentation needed to assist in determining eligibility and are aware that all information and documents provided are a matter of public record. 
_______________________________		____________________________________
Applicant Signature 			Date		Co-Applicant Signature 	    		Date