Home Modification & Accessibility Grant Program

Home Modification & Accessibility

Grant Program

What is the purpose of the Home Mod & Accessibility grant program?

The purpose of the program is to provide housing accessibility modifications for eligible

applicants who are Alaska Mental Health Trust beneficiaries and individuals with disabilities or

special needs that will extend their ability to live independently in the community. Home

modification will allow eligible individuals to overcome roadblocks in realizing an enhanced

quality of life while attaining the highest level of self-sufficiency possible.

What is the maximum grant amount?

Up to $15,000 is available to qualified beneficiaries or individuals with a single-family, owner-

occupied home, or up to $12,000 for applicants who live in rental housing. There are no income

limits or age limit.

What form of assistance does the grant program provide?

Assistance is in the form of a grant to eligible applicants. Grants are made possible by funding

through a joint program of the Alaska Department of Health and Social Services and the Alaska

Mental Health Trust Authority.

What types of property are eligible?

 The residence must be within the Municipality of Anchorage and must be a single-family, owner-

occupied dwelling that is used as the principal residence of the applicant.

 For applicants who live in rental housing, and whose improvements exceed $2,500, the

recipient will be required to have a minimum two-year lease.

What funds may be used for and who can participate?

 Bathroom modifications (such as installing grab bars, raising toilet height, adding tub chairs).

 Installation of additional handrails to stairs or installing a chair glide and/or installation of ramps.

 Adapting the environment to manage behavioral issues associated with Alzheimer’s disease

and related disorders or to mitigate any functional losses due to traumatic head injuries.

 Devices to assist hearing and/or sight impaired individuals.

 Alaska Mental Health Trust beneficiaries and individuals with disabilities or special needs who

have need for accessibility accommodations, as documented by a medical professional,

caseworker, or caregiver familiar with applicant’s needs.

 The property must be the primary residence of the applicant for 3 years after completion of the

modification. If the property is no longer occupied by a person with special needs within the 3

year period, all grant funds used must be repaid.

 The applicant must be able to provide evidence of ownership or, if a rental property, must have

a lease of appropriate length and the landlord’s consent.

 Other modifications that meet the program’s goals for accessibility and extending the ability to

live independently.

 There are no income or age limits.

For More Information: Call 677-8490 and ask to speak with our Grant Coordinator.

me Modification & Accessibility Grant Program

Checklist

The items listed below are required to process your application,

please include these documents with your application. Original

signatures are required – we cannot accept fax or email copies:

� W

arranty Deed or DMV Title (Proof of Ownership)

� Copy of picture ID (Driver’s License or State of AK I.D Card)

� If minor child is applicant, provide birth certificate or guardianship

documents

� Referral Letter from Doctor or Care Provider certifying that the

requested accessibility is directly related to the recipients needs

� If rental property, Landlord consent for repair form is required and a

copy of lease agreement

� If condominium - condo consent form from HOA

� If mobile home – mobile home park consent form

� Other documentation necessary for grant (i.e. conservatorship, etc.)

NCOMPLETE APPLICATIONS WILL NOT BE PROCESSED*

**PLEASE NOTE WE CANNOT REIMBURSE FOR ITEMS

ALREADY PURCHASED***

NeighborWorks® Alaska

2515 A Street

Anchorage, Alaska 99503

(907) 677-8490  Fax (907) 677-8450

www.nwalaska.org

Mental Health Home Modifications and Upgrades to Retain

Housing FY2021 Grant

OLD HARMLESS AND INDEMNIFICATION

I agree to defend, indemnify and hold harmless Anchorage Neighborhood Housing

Services Inc. dba NeighborWorks® Alaska and its representatives, employees,

members, officers and directors against any loss, damage, injury, or claim that may

arise in connection with acts performed on my behalf, which would reasonably be

associated with consultation, technical advice, property inspection, or other related

activities in connection with the home modification grant.

Any statements, representations, or conclusions offered by the inspector are the

considered opinion of the inspector and do NOT constitute an express or implied

warranty of any kind. NeighborWorks® Alaska, its officers, employees, and agents

shall not be liable for any direct, special, incidental, or consequential damages

under any circumstances whatsoever, whether arising in tort, negligence, or

contract, nor for any loss, claim, expense, or damage caused by or arising out of

NeighborWorks® Alaska’s inspection or supervision of a rehabilitation project.

NeighborWorks® Alaska will not indemnify or hold others harmless for any loss,

claim, expense, or damage arising out of NeighborWorks® Alaska’s inspection or

supervision of a rehabilitation project. The only warranty in effect will be that of the

Contractor for work performed and materials used.

Applicant

Co-Applicant

Date

2515 A Street, Anchorage, AK 99503

P: 907.677.8490 F: 907.677.8450 www.nwalaska.org

Home Modification & Accessibility Grant Program

(For Mental Health Trust Beneficiaries and/or individuals with special needs)

Applicant Information

(Please print a response to every question)

Name of grant recipient_____________________________________________________

Name of person completing the application______________________________________

_______________________________________________________________________________________

Mailing Address City State Zip

________________________________________________________________________

Residence Address or Physical Address City State Zip

Home Phone Cell Phone Email __________________

Are you the Owner of Record for your home? Yes No If No, provide the

information below.

Owner’s Name Phone

Mailing Address City State Zip

Household Information

List all household members, including Head of Household. Attach another page, if needed.

Name

Male

Female

Head of

Household

Disabled

Age

American Indian or

Alaska Native

Native Hawaiian or

Other Pacific

Islander

Asian

Black or African

American

White

Hispanic or Latino

Not Hispanic

Note: Ethnicity information is for government monitoring purposes only.

Rev. 02/2021

Education: □ Below High School □ High School Diploma or Equivalent □ Two-Year College

□ Bachelor’s Degree □ Master’s Degree □ Above Master’s Degree

Are you a Veteran? Applicant: □ Yes □ No Co-Applicant: □ Yes □ No

Are you foreign born? □ Yes □ No What is your primary language?_________________

If any household members are living in the home on a temporary basis, please explain:

Read “How do I Know if Someone is a Beneficiary of the Trust” on Page 5, and write the total

number of household members who have disabilities that fall within each category:

Mentally Ill

Chronic Alcoholic with Psychoses

evelopmentally Disabled

5)_____

Alzheimer’s Disease or Related Disorders

Disabled or Special Needs

Provide a letter from a medical or rehabilitation professional stating that the proposed home

improvements are necessary to improve accessibility for the disabled person living in the

household or to mitigate the persons functional limitations that result from their condition.

This letter may not be written by a household member.

Project Information

Properties Must Be Located Within the Municipality of Anchorage

Available Improvements--Housing Modification Grants may be used to improve accessibility

or to mitigate the persons’ functional limitations that result from their condition in existing

permanent or rental housing through facility modifications and improvements, including:

 Stairway modification or ramp installation or modification

 Widening of doors and/or hallways

 Adjustments to the levels of countertops and other usable surfaces;

 Installation of appropriate bathroom fixtures

 Adjustments and adaptations to improve mobility within the interior living space

 Adaptations to mitigate any functional losses due to traumatic head injuries

 Adaptations to manage behavioral issues associated with Alzheimer’s disease and related

disorders

 Installation of permanent technological features designed to improve accessibility and independent

living

 Amplification, visual devices, and/or signaling devices to assist hearing and/or visually impaired

individuals

 Other housing modifications specifically approved by the Department of Health & Social Services.

Rev. 02/2021

Special Grant Conditions

• Individuals who receive funds for personal housing modifications will be required

to sign a Promissory Note for a period of three years as a security agreement. If

the property is no longer occupied by a person with special needs relevant to the

improvements which were made during the period, all grants funds used for

the improvements must be repaid to NeighborWorks Alaska These recouped

funds will be used for the purpose of assisting another qualifying applicant with

modifications or repaid to the State of Alaska unless otherwise agreed to by both

parties. Exceptions include but are not limited to: the death of the individual or

they are no longer physically able to live in the property.

• Applicants will be required to limit expenditures for rental property to no more

than $12,000 per home. Improvements up to $2,500 require the recipient to have

in effect a minimum one-year lease. Improvements over $2,500 require the

recipient to have in effect a minimum two-year lease.

• A sample of the promissory note is attached as exhibit A to the application

• An annual occupancy letter will be sent to the recipient for a period of 3 years

from the completion of the grant. The recipient will sign and return the

occupancy letter to NeighborWorks Alaska upon receipt of the letter.

• The maximum grant amount for owner occupied properties is $15,000 and

$12,000 for rental properties. The maximum grant amounts include the HomeMap

Assessment, construction costs including project management.

______ Applicant has read, understands and agrees to the special grant conditions

Initials

Please explain what available improvement can meet your household’s accessibility needs.

Be as specific as possible and attach another page if necessary. Submit pictures of the

area(s) to be improved so we can understand your needs.

___________________________________________________________________________

Have you obtained any bids for the work identified above? If so, please provide copies.

Is there an emergency circumstance that threatens the ability of a household member to

remain in the home? If so, please describe. Attach another page if necessary.

Rev. 02/2021

***PLEASE NOTE WE CANNOT REIMBURSE FOR ITEMS ALREADY PURCHASED***

Have you applied to any other agency for assistance in meeting these needs? If so, please

provide the following contact information. Attach another page if necessary.

Agency Name

Contact Person

Phone

Referred by (please check all that apply):

□ Print Advertisement □ Bus Advertisement □ Bank □ Government □ TV □ Realtor

□ Staff/Board member □ Walk-In □ Friend □ Radio □ Newspaper Article

Walk Away Policy: The program administrator may exercise discretion, up to and including

walking away from the project, in servicing clients when the scope of work exceeds the

limitations set for this program or when other detrimental circumstances are associated with

the project, location, or applicant. These circumstances may include, but are not limited to, the

following.

A. The program administrator may implement corrective actions including walking away

when circumstances endanger workers or contractors.

B. Remedial actions including walk-away may be engaged when encountering a hostile

homeowner.

C. Finally, measures may be taken, up to and including walking away, when criminal

activities are encountered at or associated with the property, the applicant, or the

applicant’s household.

Rev. 02/2021

Applicant Certification

I certify that the above information is true and correct to the best of my knowledge and that all

adult household members have completed the Authorization for Release of Information on

Page 7.

Penalty for False or Fraudulent Statements: USC Title 18, Section 1001

provides that:

(a) Except as otherwise provided in this section, whoever, in any matter within the

jurisdiction of the executive, legislative, or judicial branch of the Government of

the United States, knowingly and willfully—

(1) falsifies, conceals, or covers up by any trick, scheme, or device a material

fact;

(2) makes any materially false, fictitious, or fraudulent statement or

representation; or

(3) makes or uses any false writing or document knowing the same to contain any

materially false, fictitious, or fraudulent statement or entry;

shall be fined under this title, imprisoned not more than 5 years or, if the offense

involves international or domestic terrorism (as defined in section 2331),

imprisoned not more than 8 years, or both. If the matter relates to an offense

under chapter 109A, 109B, 110, or 117, or section 1591, then the term of

imprisonment imposed under this section shall be not more than 8 years.

Reasonable Accommodation: If you or any person in your household needs additional

accommodation because of a disability, please explain the accommodation needed on the

“Reasonable Accommodation Request Form” provided by the sponsoring organization.

Signature of Head of Household Date

Signature of Co-Applicant Date

***PLEASE NOTE WE CANNOT REIMBURSE FOR ITEMS ALREADY PURCHASED***

Rev. 02/2021

How do I know if someone is a beneficiary of the Trust? Beneficiaries of The Trust include

the following broad groups of individuals:

People with mental illness - Statutory definition [AS 47.30.056(d)]

: Persons with the following mental disorders:

• Schizophrenia;

• Delusional (paranoid) disorder;

• Mood disorders; Anxiety disorders;

• Somatoform disorders;

• Organic mental disorders; Personality disorders; Dissociative disorders;

• Other psychotic or severe and persistent mental disorders manifested by behavioral changes and

symptoms of comparable severity to those manifested by persons with mental disorders listed in this

subsection; and

• Persons who have been diagnosed by a licensed psychologist, psychiatrist, or physician licensed to

practice medicine in the state and, as a result of the diagnosis, have been determined to have a

childhood disorder manifested by behaviors or symptoms suggesting risk of developing a mental disorder

listed in this subsection.

People with developmental disabilities - Statutory definition [AS 47.30.056(e)]

: People with the following neurological or

mental disorders:

• Cerebral palsy; Epilepsy; Mental retardation; Autistic disorder;

• Severe organic brain impairment;

• Significant developmental delay during early childhood indicating risk of developing a disorder listed in

this subsection;

• Other severe and persistent mental disorders manifested by behaviors and symptoms similar to those

manifested by persons with disorders listed in this subsection.

• Is attributable to a mental or physical impairment or combination of mental and physical impairments;

• Is manifested before the person attains age 22;

• Is likely to continue indefinitely;

• Results in substantial functional limitations in three or more of the following areas of major life activity:

self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent

living, and economic self-sufficiency; and

• Reflects the person's need for a combination and sequence of special, interdisciplinary, or generic care,

treatment, or other services that are of lifelong or extended duration and are individually planned and

coordinated.

People with chronic alcoholism - Statutory definition [AS 47.30.056(f)]

: People with the following disorders:

• Alcohol withdrawal delirium (delirium tremens);

• Alcohol hallucinosis; Alcohol amnesiac disorder;

• Dementia associated with alcoholism;

• Alcohol-induced organic mental disorder; Alcoholic depressive disorder;

• Other severe and persistent disorders associated with a history of prolonged or excessive drinking or

episodes of drinking out of control and manifested by behavioral changes and symptoms similar to those

manifested by persons with disorders listed in this subsection.

People with Alzheimer’s disease and related dementia - Statutory definition [AS 47.30.056(f)]

: People, who as a result

of their senility, exhibit one or more of the following mental disorders:

• Primary degenerative dementia of the Alzheimer type;

• Multi-infarct dementia; Senile dementia; Pre-senile dementia;

• Other severe and persistent mental disorders manifested by behaviors and symptoms similar to those

manifested by persons with disorders listed in this subsection.

For more information please see the following link: http://www.mhtrust.org/index.cfm

NeighborWorks® Alaska

2515 A Street

Anchorage, AK 99503

(907) 677-8490 Phone (907) 677-8450 Fax

Home Modification & Accessibility Grant Program

(for Mental Health Trust Beneficiaries and/or individuals with special needs)

Authorization for Release of Information

Consent

I authorize and direct any Federal, State, or local agency, organization, business, or individual

to release to Anchorage Neighborhood Housing Services Inc. (ANHS) dba NeighborWorks Alaska to

complete and verify my application for assistance under the Home Modification Grant Program.

I understand and agree that this authorization or the information obtained with its use may be

given to and used by ANHS dba NeighborWorks Alaska, State of Alaska Department of Health and

Social Services, Alaska Housing Finance Corporation, and the Alaska Mental Health Trust in

administering and enforcing program rules and policies.

I understand that I will be required to sign a Promissory Note for a period of three years as a

security agreement. Within the three year period, if the property is no longer occupied by a person with

special needs relevant to the improvements made, all grant funds must be repaid to the State of

Alaska, unless otherwise agreed to by both parties.

Information Covered

I understand that previous and current information regarding my household and me may be

needed as it relates to this program. Groups of individuals that may be asked to release this type of

information include but are not limited to:

Banks and other Financial Institutions

Medical and Psychiatric Personnel

Child Care Providers

Public Assistance Agencies

Child Support and Alimony Providers

Recording offices

Drug and Alcohol Treatment Personnel

Social Security Administration

Family and/or State-Appointed Guardians

Title Companies

Conditions

I agree that a photocopy of this authorization may be used for the purposes stated

above. The original of this authorization is on file at ANHS dba NeighborWorks Alaska. I

understand I have a right to review my file and correct any information that is incorrect. If the

modification can be made to help a minor child living in the parent or guardian’s home, the

parent or guardian would sign below

Signatures Required

Applicant’s Signature Printed Name of Applicant Social Security Number Date

Adult Member’s Signature Printed Name of Adult Member Social Security Number Date

Adult Member’s Signature

Rev. 02/2021

Printed Name of Adult Member Social Security Number Date

Home Modification & Accessibility Grant Program

(for Mental Health Trust Beneficiaries and/or Special Needs)

Referral Form

Someone such as a physician, case manager, care provider or care coordinator, may complete

this letter, it cannot be written by a household member.

Name of person applying for grant: _____________________________________________

Name of person completing application: _________________________________________

Residence Address: __________________________________________________________

Physician/Referral Agency: ____________________________________________________

Phone Fax _____________________________

Please read, “How do I know if someone is a Beneficiary of the Trust” on Page 5 of the Home

Modification Grant Program Application and indicate the eligible disability of the applicant below:

1) _____ Mentally Ill 3) _____ Chronic Alcoholic with Psychoses

2) _____

Developmentally Disabled 4)

_____

Alzheimer’s Disease or Related Disorders

5) _____ Disabled and/or Special Needs

he following proposed modification to the applicants property is directly related to that’s persons

disability. The home improvements are necessary to improve accessibility for the disabled person living

in the household or to mitigate the person(s) functional limitations that result from their condition.

roposed Modification: (Please Complete)_________________________________________________

___________________________________________________________________________________

Signature Referral Agency (if applicable)

Name (print or type) Phone

_______

Address Date

rev. 02/2021

Consent Form from the Condo Association Board for

Home Modification & Accessibility Grant Program

I, ________________________________, ____________________ of the

(Print Name) (Title)

Condo Board for ______________________________________________

(Condominium Project Name)

located at ________________________________________________ permit

(Address)

accessibility improvements to be constructed at the above mentioned address.

_______________________________________

Signature

_______________________________________

Date

** Use this form or please provide a letter from the management company or the president of

the condo board approving this disability access improvement. **

Consent by Manufactured Housing Community

Property Owner/Manager for Municipal Housing Programs

I _____________________________________________________________, Owner/Manager

Of the property commonly called: ________________________________________________

located at (address): ____________________________________________________________,

Will permit repairs and improvements (“Program Repairs”) funded in conjunction with various

Municipal housing programs. Consent is valid for all repairs begun within 3 years of the date of

the signature below.

For the mobile home of: _________________________________________________________

located at (tenant address): _______________________________________________________.

I also agree that commencing on the date Program Repairs begin and ending 18 months

following the date Program Repairs are complete, as defined by the Municipality (“Completion

Date”), I will not increase rents on spaces/lots unless those increases are demonstrably related to

matters other than the Program Repairs performed. Such matters may include increases in

property taxes or increases in utilities paid by owner in excess of 25% per year. Any increases

should be applied equally to all spaces/lots on the property.

Furthermore, commencing on the date Program Repairs begin and ending 18 months following

the Completion Date, I shall not terminate or evict any tenants of spaces/lots receiving Program

Repairs, including both those tenants that were current during the Program Repairs and any

subsequent tenants (“Covered Tenants”), provided that the Covered Tenants comply with all

obligations owed to the property owner/manager in accordance with any leases or rental

agreements between the owner/manager and tenants.

In addition to the provisions outlined above, all provisions of the Alaska Uniform Landlord and

Tenant Act apply to the Owner/Manager and all Covered Tenants.

Phone Number

__________________________________________ ______________

Signature of Owner/Manager Date

__________________________________________ ______________

Signature of Tenant/Applicant Date

Rev: 02/2021

LANDLORD CONSENT FOR IMPROVEMENTS FOR HOME

MODIFICATION & ACCESSIBILITY GRANT PROGRAM

I, ________________________________________ owner of the apartment located at

__________________________________________________ will permit accessibility

improvements to be constructed at the above mentioned address, and I also agree not to

increase the rent for three years, due to these improvements, so long as the current tenant

complies with all ongoing obligations and responsibilities owed the landlord or owner.

I understand that I should not, as an owner, remove or cause to have removed these

accessibility improvements within five years, or fail to rent to a disabled person, without

cause.

________________________________________ ____________________

Signature of Owner Date

________________________________________ ____________________

Signature of Renter Date

Rev: 02/2021

S/HomeOwnerRehab/2018HMAG-DHSS MHT/ClientContractorAgreements/LandlordTenantAgrmt2018 Page 1 of 3

Home Modification & Upgrades To Retain Housing Grant:

LANDLORD - TENANT AGREEMENT

PERMISSION TO ENTER PREMISES / RENTAL AGREEMENT

This Landlord Tenant Agreement (the “Agreement”), is made as of this _____ day of _____________, by and between _______

(the “Tenant”), who reside(s) at _______________________ (the “Property”) and _______________________the “Owner” of the

Property, and Anchorage Neighborhood Housing Services Inc. DBA NeighborWorks® Alaska (“the Grantee”), having its

principal offices at 2515 A Street, Anchorage, AK 99503.

1. P

URPOSE. The Grantee has applied for funds from

Anchorage Neighborhood Housing Services Inc.

DBA NeighborWorks® Alaska (“ANHS”), as administrator of the Home Modification & Upgrades To Retain

ousing Grant according to the requirements in 15 AAC 154.100 and 15 AAC 151.950, and ANHS’s rules for th

Home Modification & Upgrades To Retain Housing Grant (Home Modification Grant), all as may be amended and

supplemented as needed. HOME MODIFICATION FUNDS are used, in part, to provide grants to households to make

needed accessibility modifications to a qualifying applicant’s current principal residence.

2. REPRESENTATIONS AND WARRANTEES. The Owner, Grantee and Tenant have read and understand

he Terms and Conditions identified below and agree to abide by such Terms and Conditions as part of this Agreement

3. TERMS AND CONDITIONS.

(a) PERMISSION TO ENTER. Owner/Agent authorizes the Grantee or its contractor(s) to conduct related

uilding inspections and assessments, repairs, and improvements related to the accessibility modification

ncluded in the Scope of Work. Any materials installed under this Agreement shall remain as part of th

ese

remises.

(b) AMOUNT OF GRANT. The amount of materials and labor provided by the Home Modification Program

Grantee will not exceed $12,000 per rental unit.

attached to this Agreement. The Grantee and the Owner agree that only accessibility modification work

detailed Addendum, plus any written change orders as approved by the Grantee, is eligible under this project

he Tenant and Owner understand and agree that if the Tenant or Owner request a contractor to perform work

not listed in the scope of work or on any approved change orders, the requester is solely responsible for the

payment for such additional work.

(d) INSPECTION. The Grantee shall have the right to inspect the Property during reasonable hours throughout the

course of this project. The Owner also authorizes the Grantee or ANHS to inspect the Property upon 24-hour

notice and during normal working hours.

(e) TENANT RENTS. Commencing on the date the Owner and/or Tenant signs that work is complete a

ontinuing for a period of 24 months, Owner agrees not to increase rents on units benefiting from th

modifications. If a lease in effect expires prior to the end of the 24-month period, a new lease may be signed,

ut rents will remain at the previous level until the expiration of the 24-month period, unless demonstrably

related to matters other than accessibility modification. Demonstrably related to matters other than accessibility

modification work performed is defined as an increase in excess of 25% per year in (1) Fair Market Value of

rental units, (2) property taxes, or (3) the rate of utilities paid by Owner. Any increases should be split equally

between all units in the building. This Agreement applies to present tenants and any subsequent tenants for the

24-month period. If a tenant feels they have had rents increased contrary to the provisions of this Agreement, or

feels they have received an eviction notice without cause, they may contact Alaska Legal Services or th

rantee.

(f) TENANT TENURE. Owner also agrees not to terminate or evict any covered tenants or any subsequent

tenants, commencing on the date the Owner and/or tenant signs that work is complete and continuing for a

period of 24 months. This provision is in effect provided the tenant complies with all obligations owed to the

S/HomeOwnerRehab/2018HMAG-DHSS MHT/ClientContractorAgreements/LandlordTenantAgrmt2018 Page 2 of 3

Owner in accordance with any leases or rental agreements between the Owner and tenants. This Agreement

applies to present tenants and any subsequent tenants for the 24-month period.

(g) LANDLORD TENANT LAW. In addition to the provisions outlined above, all provisions of the Alask

Uniform Landlord and Tenant Act (AS 34.03.010-380) apply to the Owner and tenants who are parties to this

Agreement.

(h) INDEMNIFICATION. The Owner shall indemnify, hold harmless and defend Alaska Housing Finance

Corporation, the State, the Grantee, their officers, agents, and employees from all liability, including costs and

penses, for all actions or claims resulting from injuries or damages by any person or property arising directly

or indirectly as a result of any error, omission or negligent act of the Grantee, its contractors or anyone directly

or indirectly employed buy the Grantee in the completion of the project or the performance of this Agreement

) VIOLATION OF AGREEMENT. Upon violation of any of the provisions of this Agreement by the Owner, the

Grantee shall give written notice thereof to the Owner, as provided below in NOTICES. If such violation is not

corrected to the satisfaction of the Grantee within thirty (30) days after the date such notice is given, or withi

ch further time as the Grantee in its sole discretion permits, the Grantee may declare a default under thi

Agreement, effective on the date of such declaration of default and notice thereof to the Owner, and upon such

fault the Grantee may: (1) terminate this Agreement; (2) exercise such other rights or remedies as may b

ailable to the Grantee, at law or in equity.

Either party to this Agreement may bring an action for specific performance of its terms. Tenants residing in

dwelling units covered by this Agreement are intended third-party beneficiaries of any of the provisions of the

Agreement related to rental increases, evictions, and terminations of tenancies.

(j) AMENDMENT. This Agreement shall not be altered or amended except in writing signed by the parties

hereto.

(k) NOTICE. Any notice, demand, request or other communication that any party may desire or may be required t

give to any other party hereunder shall be given in writing, at the addresses set forth above, by any of the

following means: (1) personal service; (2) electronic communication, whether by telegram or telecopier,

together with confirmation of receipt; (3) overnight courier; or (4) registered or certified United States mail,

postage prepaid, return receipt requested. Such addresses may be changed by notice to the other party given in

the same manner as herein provided. Any notice, demand, request or other communication sent pursuant t

either subsection constitute one and the same agreement.

(l) SALE OR TRANSFER OF PROPERTY OR CHANGE IN TENANT. This Agreement shall run with the la

nd/or modified unit in the case of sale or transfer to other owner/agents. The Owner is responsible to give

official notice of this Agreement to any subsequent owners.

(

m) CHANGE IN TENANTS. This Agreement applies to present tenants and any subsequent tenants for the 24-

month period, and the Owner agrees to provide subsequent tenants with a copy of this Agreement.

[Tenant must fill out and sign below]

The Tenant represents and warrants as follows:

TENANT Certification

I, ____________________________________, certify my permanent residence is a dwelling unit located at:

Name (Please print.)

Residence or Physical Address City State

I further certify that I am, in need of the accessibility modifications covered under this Agreement, and do not have nor

do I know of other resources that could fund these modifications. I have read and understand the terms of this

Agreement.

Signature – Tenant/Grantee Date

S/HomeOwnerRehab/2018HMAG-DHSS MHT/ClientContractorAgreements/LandlordTenantAgrmt2018 Page 3 of 3

[Owner must fill out and sign below]

e Owner represents and warrants as follows:

WNER / AUTHORIZED AGENT Certification

I, , certify that I am the Owner/authorized agent, herein

Name (Please print.)

referred to as "Owner" for the Property located at:

Residence or Physical Address City State

The Property is presently rented to the following Tenant(s) who will benefit from the accessibility modifications, herein

referred to as “Tenant”: for $ rent

per  month  year (check one).

I have read and agree to the terms of this Agreement.

Signature of Owner / Authorized Agent * Date

Mailing Address City State Zip

Phone No.: Fax No.: Msg. No:_______________

ENTS: INCLUDE A COPY OF YOUR AGENT AGREEMENT WITH THE OWNER AND PROOF OF

OWNERSHIP.

FOR OFFICE USE ONLY [Grantee must sign below]

The Grantee represents and warrants as follows:

HOME MODIFICATION PROGRAM GRANTEE AUTHORIZED AGENT Certification

I have read and agree to the terms of this Agreement.

__________

Date

________________________________________________________

Signature of Home Modification Program Grantees Authorized Agent

NeighborWorks® Alaska, 2515 A Street, Anchorage, AK 99503

office: 907-677-8490/ fax: 907-677-8450

Promissory Note: Page 1 of 2

Exhibit A

PROMISSORY NOTE

To be used to secure improvements made through the

HOME MODIFICATION & UPGRADES TO RETAIN HOUSING GRANT

TRUSTOR: ___________

TRUSTEE: Anchorage Neighborhood Housing Services, Inc. dba NeighborWorks® Alaska

SECURED AMOUNT: $

COMMENCEMENT DATE: Date of final

TERMINATION DATE: _______________

This note secures improvements made to the residence located at Property Address for a

period of three (3) years beginning on the COMMENCEMENT DATE, _ Date of Final, hereafter

referred to as the TRUSTOR, agrees that he/she and his/her mother/father (optional) will remain

as permanent residents at this location through at least Three years from date of final hereafter

referred to as the TERMINATION DATE.

The intent of this Promissory Note is to secure performance by the TRUSTOR of their use of the

improvements on the real property for a period of not less than three (3) years. If for any reason,

the TRUSTOR and/or his mother/father vacate the premises prior to the TERMINATION

DATE, a pro-rated portion of the SECURED AMOUNT must be repaid to the TRUSTEE as

described below.

For value received, the TRUSTOR promise(s) to pay to the TRUSTEE, the pro-rated outstanding

balance. All obligations set forth herein are measured from the COMMENCEMENT DATE.

The COMMENCEMENT DATE is the date, determined by the TRUSTEE, that all work was

determined to be substantially complete.

There shall be no interest paid on the initial indebtedness. The amount of initial indebtedness shall

decrease by 33% on the first and second anniversary and by 34% on the third anniversary of the

COMMENCEMENT DATE so that at the expiration of the 3-year period, the interest of the

TRUSTEE in the real property shall be zero and this Note shall be satisfied, therefore

automatically releasing the TRUSTEE’s interest in the real property on the TERMINATION

DATE.

In the event of a default under the terms of this Note by the TRUSTOR, the TRUSTEE, may

declare, by written demand, all of the SECURED AMOUNT and interest due and payable within

ten days.

Promissory Note: Page 2 of 2

In the event legal action is brought to recover on, or to secure payment on, the within Note, or in

the event any party hereto, files an action to interpret any provisions of this Note, the prevailing

party in such action shall be entitled to such legal fees and costs of suit as determined by a court

of law of competent jurisdiction to have been reasonably incurred in such action.

No provisions of this Note may be amended, modified, supplemented, changed, waived,

discharged or terminated unless the TRUSTEE consents in writing. In case any one or more of

the provisions contained in this note should be held to be invalid, illegal or unenforceable in any

respect, the validity, legality and enforceability of the remaining provisions contained herein shall

not be affected or impaired.

This Note shall be governed by and construed in accordance with the laws of the State of Alaska.

_________________________________________ ________________________

Signature of Trustor – Date

Name: Borrower

Address: XXXX street

City State: Anchorage, AK 99503

IN WITNESS WHEREOF, TRUSTOR has executed this note on the Date of this Note

___________________________________________ ___________________

Witness Signature Date

___________________________________________

Witness Printed Name

Client Information Print Name: ________________________________

ce:

Alaskan Native/American Indian

Asian

Black / African American

Multiple Races

Native Ha

waiian

& Other Pacific Islander

White

Other

Ethnicity:

Hispanic

Non-Hispanic

Gen

der: (circle one)

Male / Female /

Other

Primary Language: Birth Country: __________________

Marital Status: (circle one) Single Married Divorced Separated Widowed

Education

years

Active Military: Y N (circle one) Veteran: Y N (circle one) Date of Birth:

______________

Household Information

Number of people in your household:________ Number of dependents: _________

nt / Own? (circle one)

nual Household Income: (circle one)

Under

$25,000 $25,000 - $29,999 $30,000 - $39,999 $40,000 - $49,999 $50,000 - $59,999

$60,000 - $75,000 $75,001 - $100,000 $100,001 - $150,000 Over $150,000

NeighborWorks® Alaska takes the privacy of its customers very seriously. We will only disclose the above demographic

information to non-financial

companies such as HUD (Housing and Urban Development) and Neighborhood Housing

Services of America (NHSA), but only for program review,

auditing, research and oversight purposes.