S:\Human Services\HSNG\Forms\HOME\HOME Application 7.1.23.docx Effective Date: 07-01-23 1
LEE COUNTY HOME DOWN PAYMENT ASSISTANCE PROGRAM
Dear Future Lee County Homeowner / Interested Lender or Realtor:
Thank you for inquiring about the HOME Down Payment Assistance Program. Please
note that the application process may take up to 4 to 6 weeks depending on completeness
of the application. Funds are available on a first come-first ready basis for homebuyers
who meet the program requirements.
This program is for the purchase of existing homes located anywhere in Lee County. A
unit which has obtained a Certificate of Occupancy at least one year prior to making
application is eligible (no new construction).
The home being purchased must be a single family home, condo/PUD or double-wide
mobile/manufactured home (if 1978 or newer and situated on owned land). Duplexes,
homes with attached or detached mother-in-law units, and homes with pools are not
eligible. Maximum purchase price for the property is $309,000 (effective 7/1/2023).
Homebuyers must agree to occupy the property as their principal homesteaded
residence and not own any other homes at the time of application.
Homebuyers are required to attend a Homebuyer Education Workshop from a HUD
approved housing counseling agency. The following agencies may offer such courses:
• .................................................................. Lee County Housing Development Corporation
..............................................................................Phone: 239-275-5105
• .................................................................. Affordable Homeownership Foundation Inc.
..............................................................................Phone: 239-689-4944
• .................................................................. Habitat for Humanity of Lee & Hendry Counties
• .................................................................. Phone: 239-652-1675
• .................................................................. Housing Authority of the City of Fort Myers
..............................................................................Phone: 239-344-3220
Homebuyers must obtain a loan commitment for a new first mortgage from a licensed
lending institution. Our program is open to all lenders; no approval process is required.
For approved applicants, Lee County will determine the minimum amount of down
payment/closing cost assistance based on need. We will look at the lender required
minimum down payment and closing costs (less earnest money deposit paid up front).
Maximum assistance in any case is 10% of the purchase price or $24,500, whichever is
less. The home must appraise at or above the sales price in order to qualify for assistance.
Funds are available on a first come-first ready basis. To confirm availability of funds,
contact Lee County.
▪ An ORIGINAL completed application along with a copy of a fully executed purchase
contract is required to be submitted by the lender directly to Lee County at the address
below:
Lee County Human and Veteran Services
Attn: Debbie Curran
2440 Thompson Street
Fort Myers, FL 33901
Kevin Ruane
District One
Cecil L Pendergrass
District Two
Ray Sandelli
District Three
Brian Hamman
District Four
Mike Greenwell
District Five
Roger Desjarlais
County Manager
Richard Wm. Wesch
County Attorney
Donna Marie Collins
Hearing Examiner
S:\Human Services\HSNG\Forms\HOME\HOME Application 7.1.23.docx Effective Date: 07-01-23 2
CHECKLIST FOR SUBMISSION
Applicant’s Name:
The items listed below are required to be submitted at time of initial application:
Documentation (please put application package in this order; top to bottom)
Received
Lender Referral Form
HOME Application (3 Pages) – Must be completed and signed by all ADULT household
members
Terms of First Mortgage
Authorization For the Release of Information - Must be signed by all ADULT household
members
Purchaser’s Acknowledgement of Monitoring Performance
Conflict of Interest Disclosure-Must be signed by all ADULT household members
Purchaser’s Acknowledgement of Terms
Notice Regarding Collection of Social Security Numbers
Copies of Photo ID’s for all ADULT household members
Copies of Social Security Cards for all household members
Copies of Permanent Resident Alien Cards for all household members, if applicable
Copies of Birth Certificates for all household members under 18
Copy Signed First Mortgage Loan Application (1003)
Copy Signed First Mortgage Loan Estimate
Copy of First Mortgage Loan Pre-Approval
Copies of Verifications of Income, including VOE’s for all sources of income, including full-
time and part-time employment, social security awards letters, pension, child support,
alimony, unemployment, worker’s comp., etc. Verifications of Income must be included for
ALL household members
Copies Current pay-stubs (2 months) for ALL household members
Copy Current Year Federal Income Tax Returns, all pages and all schedules including W-2’s,
1099’s, etc.
Copies 2 Years of Tax Returns for all self-employed borrowers including signed/dated
Year-to-Date Profit and Loss, if applicable
Copy Divorce Decree, if applicable
Copy Child Support Court Order Documentation/Verification, if applicable
Copies Verifications of Deposit (VOD’s) for all asset accounts including interest rates on all
accounts, including checking, savings, money market accounts, CD’s, IRA’s, 401(k), or other
retirement accounts, etc. Must be provided for ALL household members
Copies Current two months Bank Statements for all asset accounts including checking,
savings, money market accounts, CD’s, IRA’s, 401(k), or other retirement accounts, etc. Must
be provided for ALL household members
Copy Fully Executed Purchase Contract with all applicable addendums, i.e. lead based paint
addendum for homes built prior to 1978
These items are required to be submitted prior to closing:
Copy of First Mortgage Loan Commitment/Approval
Copy Homebuyer Education Certificate
Verification of Earnest Money Deposit paid
Copy Appraisal
For homes built prior to 1978, Certified Lead Based Paint Inspection performed by EPA/HUD
approved lead based paint inspector or certified risk assessor (order after HOME approval)
Seller Signed Uniform Relocation Act Disclosure
NOTE: Incomplete applications will be sent back to the submitting lender without processing.
S:\Human Services\HSNG\Forms\HOME\HOME Application 7.1.23.docx Effective Date: 07-01-23 3
LENDER REFERRAL FORM
The applicant identified below appears to meet the eligibility requirements of Lee County’s HOME Down
Payment Assistance Program based on preliminary information received during their mortgage application.
Applicant(s) Name:
Subject Property Address:
Date Request Submitted:
Anticipated Closing Date:
DPA Amount Requested:
$
Other Assistance:
$
Household Size:
Debt-to-Income Ratios:
/
Lending Institution Information
Lending Institution:
Lender Address:
Loan Officer:
Loan Processor:
LO Phone:
LP Phone:
LO Fax:
LP Fax:
LO E-mail:
LP E-mail:
Closing Agent Information
Closing Agent Company:
Closing Agent Address:
Closing Agent Contact:
Closing Agent E-mail:
Closing Agent Phone:
Closing Agent Fax:
Inspection Contact Information – Listing/Selling Agent
Listing Agent Company:
Listing Agent Contact:
Listing Agent E-mail:
Listing Agent Phone:
Listing Agent Fax:
Selling Agent Company:
Selling Agent Contact:
Selling Agent E-mail:
Selling Agent Phone:
Selling Agent Fax:
Signature of Loan Agent Date
PROCESSING TIME CAN TAKE UP TO 30 WORKING (BUSINESS) DAYS!
PRELIMINARY APPLICATION CAN BE SUBMITTED VIA EMAIL, U.S. MAIL, OR IN PERSON.
FAXED APPLICATIONS WILL NOT BE ACCEPTED.
Instructions: Submit all items from Checklist for Submission to:
Lee County Human and Veteran Services
2440 Thompson Street
Fort Myers, FL 33901
ATTN: Debbie Curran
S:\Human Services\HSNG\Forms\HOME\HOME Application 7.1.23.docx Effective Date: 07-01-23 4
Applicant Information (all adult household members must complete/sign; use separate sheets as necessary):
Applicant/Co-
Applicant General
Information
Applicant
Co-Applicant
Full Legal Name:
Social Security #:
Date of Birth:
Street Address:
City, State Zip:
Length at address:
Home Phone:
Cell: Phone:
Work Phone:
E-mail Address:
Marital Status:
Declarations (circle one for each question):
Applicant
Co-App
Are you a US Citizen?
Yes
No
Yes
No
Are you a Permanent resident alien?
Yes
No
Yes
No
Have you and/or your spouse or co-applicant owned a home in the past 3 years?
Yes
No
Yes
No
Do you have any outstanding unpaid collections or judgments?
Yes
No
Yes
No
Have you been declared bankrupt within the past 7 years?
Yes
No
Yes
No
Have you had a property foreclosed upon or given title or deed in lieu of foreclosure?
Yes
No
Yes
No
Are you a party to a lawsuit?
Yes
No
Yes
No
Have you applied for a house through any other non-profit agency?
Yes
No
Yes
No
Have you disposed of any major assets in the past two years?
Yes
No
Yes
No
If so, how much? $
Have you ever been awarded child support for any of your children, regardless of
whether or not it is received?
Yes
No
Yes
No
If yes, in what State and County was it awarded?
ALL Household Members:
Name (s)
Social Security
Number
Date of Birth
Sex
Relationship
to Applicant
Marital
Status M, S,
W, D
Citizenship
Status?
Self
Is applicant, co-applicant, or any other household member, age 18 or older, a full-time student? Yes ❑ No ❑
If yes, please list student name:
HOME Down Payment Assistance Application
S:\Human Services\HSNG\Forms\HOME\HOME Application 7.1.23.docx Effective Date: 07-01-23 5
Does anyone plan to live with you in the future who is (are) not listed above? Yes ❑ No ❑
Does the applicant or co-applicant own a home? Yes ❑ No ❑; Monthly rent/mortgage: $
Number of persons in household who are:
White
Black
Native American/Indian
Asian/Pacific Islander
Hispanic
Other
Elderly (62 and over)
Disabled
Name(s) of disabled?
Household type: Single ❑ Two-parent ❑ Single-parent ❑ Married ❑ Individuals ❑
Applicant /Co-Applicant /Other Adult Household Member 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): $
NOTE: Attach additional sheets as necessary for all household members 18 years and over.
Annual Household Income (for all household members 18 and over):
Source
Applicant
Co-Applicant
Other member(s)
18 or over
Total
Gross Salary
Overtime, Tips, Bonuses
Alimony/Child Support
Social Security
Retirement/Pension
AFDC, Welfare
Interest/Dividends
Unemployment
Workers Compensation
Net Business Income
Other
Total Annual Income
$
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Assets (for all household members):
Type
Institution
Owner
Account #
Cash Value
Checking Account
Savings Account
Money Market
Stocks, Bonds, CD’s
IRA’s, 401(k)
Equity in Properties
Life Insurance
Other
Total Assets
$
Liabilities (for all household members 18 and over including credit card debt, auto and installment debt):
Type
Creditor’s Name
Monthly Payment
Balance
Rent/Lease Payment
N/A
Mortgage
Total Liabilities
$
$
How did you hear about the HOME program?
WARNING: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making
false or fraudulent statements to a department of the United States Government; which is punishable under the provisions of Title 18,
Section 1014 of the U.S. Code.
WARNING: Florida Statute 817 provides that willful false statements or misrepresentation concerning income and assets or liabilities
relating to financial condition is a misdemeanor of the first degree and is punishable by fines and imprisonment provided under S
775.082 or 775.083
I/We 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 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.
I certify that the above information is true and correct. I also understand that it is my responsibility to report all
changes to my household composition or income in writing, within ten (10) business days of such change.
Applicant’s Signature Date Co-Applicant’s Signature Date
Other Adult Household Member Signature Date Other Adult Household Member Signature Date
S:\Human Services\HSNG\Forms\HOME\HOME Application 7.1.23.docx Effective Date: 07-01-23 7
TERMS OF FIRST MORTGAGE
(to be completed by Mortgage Loan Officer)
Borrower’s Name:
Property Address:
Lending Institution:
First Mortgage Terms
1. Loan Amount: $
2. Loan Type ❑ Conventional Conforming
❑ Conventional Non-Conforming
❑ FHA
❑ VA
❑ USDA
3. Loan Term: ❑ Years ❑ Months
4. Interest Rate: % Locked In? ❑ Yes ❑ No
5. Fixed Rate? Lender Required Minimum Down Payment: %
The above borrower is applying for assistance through Lee County’s HOME Down Payment Assistance Program.
The undersigned loan officer hereby declares that the above first mortgage loan information is true and correct.
If any of the above terms change between now and closing, the undersigned loan officer will immediately
contact Lee County Human and Veteran Services (LCHVS). Any approval given by LCHVS may be declared null
and void if any of the above information changes and is no longer acceptable to LCHVS.
Acknowledged by:
Applicant’s Signature Date Co-Applicant’s Signature Date
Loan Officer Signature Date Loan Officer Printed Name
S:\Human Services\HSNG\Forms\HOME\HOME Application 7.1.23.docx Effective Date: 07-01-23 8
AUTHORIZATION FOR THE RELEASE OF INFORMATON
I/We, , the undersigned hereby
authorize the release without liability, of information regarding my/our employment, income, and/or assets to
Lee County Human and Veteran Services, for purposed of verifying information provided as part of determining
eligibility for assistance under the HOME Down Payment Assistance Program. I/We understand that only
information necessary for determining eligibility can be requested.
Type of Information to be verified:
I/We understand that previous or current information regarding me/us may be required. Verifications that
may be requested are, but not limited to: personal identity, employment history, hours worked, salary and
payment frequency, commissions, raises, bonuses and tips; cash help in checking/savings accounts, stocks,
bonds, certificate of deposits, Individual Retirement Accounts, interest dividends; payments from Social
Security, annuities, insurance policies, retirement funds, pensions, disability or death benefits, unemployment,
disability or worker’s compensation; welfare assistance, net income from the operation of a business, and
alimony or child support payments., etc.
Organizations/Individuals that may be asked to provide written/oral verifications are, but not limited to:
Past/Present Employers
Alimony/Child Support Providers
Banks, Financial or Retirement Institutions
Social Security Administration
State unemployment Agency
Veteran’s Administration
Welfare Agency
Other
Agreement to Conditions:
I/We agree that a photocopy of this authorization may be used for the purposes stated above. I/We understand
that I/we have the right to review this file and correct any information found to be incorrect.
Applicant’s Signature Date Co-Applicant’s Signature Date
Other Adult Household Member Signature Date Other Adult Household Member Signature Date
Note: This general consent form may not be used to request a copy of a tax return. If one is needed, contact
your local IRS office for Form 4506, “Request for Copy of Tax Return” and prepare and sign separately.
S:\Human Services\HSNG\Forms\HOME\HOME Application 7.1.23.docx Effective Date: 07-01-23 9
CLIENT INFORMED CONSENT & RELEASE OF INFORMATION AUTHORIZATION
For Client Services Network of Lee County (CSN)
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. IF YOU HAVE ANY QUESTIONS OR
DESIRE ANY FURTHER INFORMATION REGARDING THIS FORM, PLEASE CONTACT THE CSN SYSTEM
ADMINISTRATOR AT (239) 533-7925.
In order to best serve your needs at Lee County Human and Veteran Services to develop meaningful treatment plans, to determine your
continuing eligibility for services, and to monitor your progress in complying with the terms of your shelter, housing or other services,
Lee County Human and Veteran Services and the Continuum of Care need to exchange, share, and/or release data, information or records
they may collect about you.
The information contained in your case records with any Agency is considered confidential and privileged and cannot be exchanged,
shared and or/released without your express and informed written consent, except where otherwise authorized by law. Please understand
that access to shelter, housing and services is available without your consent for the release of the information. However, your consent,
although optional, is a critical component of our community’s ability to provide the most effective services and housing possible.
I understand that:
▪ This Agency may not condition the provision of services to me on my signing this consent/authorization (this Agency may not
refuse to serve me simply because I do not want my information shared with other agencies).
▪ This form specifically authorizes the use of information about me in research conducted using information maintained in CSN. I
will not be personally identified by name, social security number, or any other unique characteristic in published research reports.
The type of research that will be conducted using this information includes reports on the number and characteristics of people
using different types of services, the effectiveness of services, and changes in patterns over time.
▪ If I give permission, the CSN allows information about me, including my photograph, to be shared with other CSN Partner Agencies.
This may include, but is not limited to, information regarding my education history and employment background, income, program
eligibility and participation, and personal history. The purpose of sharing information this way is to help the agencies that I seek
services from obtain information about me more quickly, assist with my case management, and to help connect me with the services
I need.
▪ Agencies that join CSN after I sign this consent/authorization also will have access to the personal information that I authorize for
data sharing. This Agency must make reasonable accommodations to allow me to view the updated list of CSN Partnering Agencies.
▪ I have the right to inspect, copy, and request all records maintained by Agency relating to the provision of services provided by
Agency to me and to receive copy of this form unless specifically denied under federal or state law. I understand that my records
are protected by federal, state, and local regulations governing confidentiality of client records and cannot be disclosed without my
written consent unless otherwise authorized by law. I may revoke this authorization at any time verbally or by written request, but
the cancellation will not be retroactive. I understand that this release is valid for one year.
I give my consent to the exchange of information on CSN: Yes No
I have read this document or it was read and/or explained to me and I fully understand and agree with the terms of this document.
Signature of client
Date:
Signature of client
Date:
Printed name of client
Printed name of client
CSN Partnering Agencies
Affordable Homeownership Foundation Inc.
After the Rain
American Red Cross
Ann’s Restoration House
Children’s Home Society of Florida
Community Assisted & Supported Living
Community Cooperative
Department of Veteran Affairs
Jewish Family & Children’s Service of the Suncoast
Lee County Department of Human and Veteran Services
Lee County Housing Development Corporation Inc.
Lee County Homeless Coalition
Lee County Pretrial Services
Lee Health
Lehigh Community Services
Oasis Luther Services
Open Arms Foundation
Public Defender’s Office
SalusCare, Inc.
The Salvation Army
Triage Outreach Center
United Way 211
UW House Interfaith Caregivers
For current agency contact information, please visit HMIS.Leegov.com
S:\Human Services\HSNG\Forms\HOME\HOME Application 7.1.23.docx Effective Date: 07-01-23 10
PURCHASER’S ACKNOWLEDGEMENT OF MONITORING PERFORMANCE
Purchaser(s) acknowledge by signing this statement that they are fully aware of and intend to abide by the
following terms and conditions:
1. Intend to occupy this property as my/our primary homesteaded residence. Lee County Human and
Veteran Services (LCHVS) will perform an annual monitoring to endure that purchaser(s) is/are still
occupying the subject property. Purchaser(s) agrees to promptly complete and return the survey letters
that will be mailed each year during the term of the Lee County mortgage (ten (10) years from closing).
2. Purchaser(s) certifies that I/we do not currently own any residential real estate property.
3. Purchaser(s) understands that this document in no way guarantees approval under Lee County’s HOME
Down Payment Assistance Program.
Does purchaser(s) presently live in subsidized housing? ❑ Yes ❑ No
Does property have a swimming pool? ❑ Yes ❑ No
Purchaser’s Acknowledgement of HUD’s Minimum Housing Quality Standards Inspection
The undersigned, , purchaser(s) of the
property located at , hereby acknowledge
that Lee County Human and Veteran Services (LCHVS) will perform an inspection to determine whether or not
the above property meets HUD’s required inspection requirements. The property must pass this inspection in
order for me/us to be eligible for HOME Down Payment Assistance. However, a passing inspection does not
guarantee HOME Down Payment Assistance funds.
I/we understand that this inspection is not and should not be considered a “Home Inspection.” Lee County
HVS recommends that I/we obtain a Home Inspection including a defective drywall inspection (Chinese
Drywall) performed by a licensed, insured independent Home Inspector/Drywall Inspector. If I/we choose to
obtain a Home or Drywall inspection, a copy will be given to Lee County HVS. I/we further understand that
Lee County HVS assumes no responsibility for the condition of the above property and does not warrant the
house in any way.
I/we are entitled to receive a copy of the HUD required inspection performed by LCHVS and will contact the
following person if I/we desire to receive a copy of the inspection report:
Lee County Human and Veteran Services
2440 Thompson Street
Fort Myers, FL 33901
ATTN: Debbie Curran
Phone: (239) 533-7938
Fax: (239) 533-7955
E-mail: [email protected]
Applicant’s Signature Date Co-Applicant’s Signature Date
Other Adult Household Member Signature Date Other Adult Household Member Signature Date
S:\Human Services\HSNG\Forms\HOME\HOME Application 7.1.23.docx Effective Date: 07-01-23 11
CONFLICT OF INTEREST DISCLOSURE
I understand that I must disclose information regarding my relationship with Lee County or with other persons who may be associated
within the County if there is real or perceived conflict of interest due to employment, financial interest, or familial or business
relationship. I, therefore, attest to the following:
❑ I am a current Lee County Board of County Commissioners’ official, employee, board member, commissioner, agent and/or other
representative of the County.
Position/Title:
❑ I am a former Lee County Board of County Commissioners’ official, employee, board member, commissioner, agent and/or other
representative of the County.
Position/Title:
Date Employment/Term Ended:
❑ I am related to or have a business relationship with a current Lee County Board of County Commissioners’ official, employee,
board member, commissioner, agent and/or other representative.
His/her name is:
The person is associated with the County in the capacity as:
The relationship of the person is as follows:
❑ Parent; ❑ Spouse; ❑ Immediate family; ❑ Business associate; ❑ Other:
❑ To the best of my knowledge, I am not aware of any current Lee County Board of County Commissioners’ official, employee, board
member, commissioner, agent and/or other representative of the County who is related to me or with whom I am a business associate.
WARNING: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false
or fraudulent statements to a department of the United States Government; which is punishable under the provisions of Title 18, Section
1014 of the U.S. Code.
WARNING: Florida Statute 817 provides that willful false statements or misrepresentation concerning income and assets or liabilities
relating to financial condition is a misdemeanor of the first degree and is punishable by fines and imprisonment provided under Statutes
775.082 or 775.083
Name (Print) Signature Date
Name (Print) Signature Date
FOR STAFF USE ONLY
In accordance with Federal regulations, this employee: Does OR Does Not exercise or has exercised any functions or
responsibilities with respect to HUD-funded activities,
and Is OR Is Not in a position to participate in the decision making process or gain inside information regarding such
activities. Therefore,
❑ No conflict exists, or
❑ Exception to a real or perceived conflict exists and an exception will be filed.
Signed by: ____________________________________ Date: ______________________________________
S:\Human Services\HSNG\Forms\HOME\HOME Application 7.1.23.docx Effective Date: 07-01-23 12
PURCHASER’S ACKNOWLEDGEMENT OF TERMS
Lee County is offering a second mortgage program which will provide assistance to enable eligible families to become
homebuyers. All assistance provided will be secured by a ten (10) year self-amortizing second mortgage on the property
being purchased and can be used for down payment AND closing costs. For approved applicants, Lee County will
determine the minimum amount of down payment/closing cost assistance based on need. We will look at the lender
required minimum down payment and closing costs (less earnest money deposit paid up front). Maximum assistance in
any case is 10% of the purchase price or $24,500, whichever is less. The home must appraise at or above the sales price
to be eligible for assistance. If all approved funds are not utilized for down payment and/or closing costs at the closing,
the title company will be required to issue a refund payable to Lee County BoCC, c/o Lee County Human and Veteran
Services. The homebuyer cannot receive any cash back, including any money paid towards earnest money deposit,
application fee, appraisal, etc. If, during the ten year term, the property is sold, transferred, leased, or first mortgage is
refinanced, or is not owner-occupied and homesteaded, then the prorated balance of the second mortgage will be due
and payable in full. Funds will be reserved on a first come, first ready basis to eligible applicants who receive firm
mortgage commitments from a licensed lending institution.
In order to be eligible for assistance, an applicant cannot own any other homes; agree to occupy the property as their
principal homesteaded residence; have executed a purchase contract for purchase of an existing single family home
(condos and PUD’s included) in Lee County; and have gross annual household income which does not exceed the limits
set forth below (Effective June 15, 2023):
1 person - $47,700
2 persons - $54,500
3 persons - $61,300
4 persons - $68,100
5 persons - $73,550
6 persons - $79,000
7 persons - $84,450
8 persons - $89,900
I/we acknowledge that this referral does not guarantee that I am approved for assistance in conjunction with Lee County’s
HOME Down Payment Assistance Program and/or permanent mortgage financing through the lender making this
referral. I authorize the lender or its designated agent to release any information necessary to determine my/our
eligibility for the program to Lee County Human and Veteran Services and/or designated agents of such.
Please list all household members, including borrower(s) names (use additional sheet as necessary):
Name
D/O/B
Relation
Social Security #
Income
SELF
WARNING: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making
false or fraudulent statements to a department of the United States Government; which is punishable under the provisions of Title 18,
Section 1014 of the U.S. Code.
WARNING: Florida Statute 817 provides that willful false statements or misrepresentation concerning income and assets or liabilities
relating to financial condition is a misdemeanor of the first degree and is punishable by fines and imprisonment provided under S
775.082 or 775.083
I/we understand that any willful misstatement of information will be grounds for disqualification. I/we certify that the application
information provided is true and complete.
Applicant’s Signature Date Co-Applicant’s Signature Date
Other Adult Household Member Signature Date Other Adult Household Member Signature Date
S:\Human Services\HSNG\Forms\HOME\HOME Application 7.1.23.docx Effective Date: 07-01-23 13
Lee County, Florida
Human and Veteran Services
(239) 533-7930
NOTICE REGARDING COLLECTION OF SOCIAL SECURITY NUMBERS
The following disclosure is being made pursuant to section 119.071(5), Florida Statutes.
Social security numbers of applicants and household members are requested because this information has been
determined to be imperative for the performance of the duties and responsibilities prescribed by law under this program.
This information is not required by state or federal law; however, third-party verifications of social security numbers are
necessary to determine eligibility for program services and specifically for the following purposes:
1. To verify an applicant’s identity.
2. To verify household size.
A social security number collected pursuant to this notice can only be used by Lee County Board of County Commissioners
for the purposes specified above.
Nondisclosure except under limited circumstances
Social security numbers will not be disclosed to others unless required or authorized by Florida law. Section 119.071(5),
Florida Statutes, allows disclosure of a person’s social security number under the following specific, limited circumstances:
• If disclosure is expressly required by federal or Florida law or is necessary for the agency or governmental entity
to perform its duties and responsibilities;
• If the individual expressly consents to disclosure in writing;
• If disclosure is made to prevent and combat terrorism pursuant to the U.S. Patriot Act of 2001 or Presidential
Executive Order 13224 (blocking property and prohibiting business transactions with persons who commit,
threaten to commit, or support terrorism);
• For an agency employee and dependents, if disclosure is necessary to administer the person’s health benefits or
pension plan funds; or
• If disclosure is for the purpose of the administration of the Uniform Commercial Code by the office of the Secretary
of State.
• If disclosure is requested by a commercial entity for permissible uses under the federal Driver’s Privacy Protection
Act of 1994, the federal Fair Credit Reporting Act, or the federal Financial Services Modernization Act of 1999 (for
example, to verify the accuracy of personal information provided by the individual to the commercial entity; use
by an insurer in connection with claims investigation or anti-fraud activities; for use in connection with a credit
transaction).
Acknowledgment of Receipt of Notice
I confirm that I have been provided a copy of this Notice regarding the collection of my social security number and the
social security numbers of all household occupants as part of the application process for this program.
______________________________________________________________ _______________________________________________________________
Applicant Signature Date Co-Applicant Signature Date
______________________________________________________________ _______________________________________________________________
Other Adult Household Member Signature Date Other Adult Household Member Signature Date
S:\Human Services\HSNG\Forms\HOME\HOME Application 7.1.23.docx Effective Date: 07-01-23 14
UNIFORM RELOCATION ACT (URA) SELLER FORM
Date:
Seller:
Homebuyer:
Subject Property Address:
To Whom It May Concern:
The Lee County Human and Veteran Services is pleased to participate in the sale of your property by assisting
the buyer through our HOME Down Payment Assistance Program.
Under HUD’s HOME Down Payment Assistance Program, the Lee County Human and Veteran Services is
mandated to inform you that any owner-occupant who voluntarily sells a property to a first-time homebuyer
is not eligible for relocation assistance under the Uniform Relocation Act (URA). The above referenced property
must be currently occupied by yourself or the purchaser, or be vacant. We will not allow a tenant to be
displaced. In addition, we are using the property appraisal as the fair market value of your property being
purchased. We also want to inform you that the buyer does not have the Power of Eminent Domain and
therefore will not acquire the property if negotiations fail to result in an amicable sales agreement.
Again, the Lee County Human and Veteran Services is happy to participate in the sale of your property thereby
creating an affordable home for this homebuyer.
If you have any questions, please contact me Monday-Friday, 7:30am-4:30pm at Lee County Human and
Veteran Services, 2440 Thompson Street, Fort Myers, FL 33901 (239.533.7938; Fax: 239.533.7955; email:
Sincerely,
Debbie Curran
Debbie Curran, Housing Finance Counselor
Lee County Human and Veteran Services
I HEREBY CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE LETTER AND ALSO CERTIFY THAT:
Please check the one that applies.
I am currently occupying the above referenced property.
The above referenced property is and was vacant at the time the purchase contract was
entered into with buyer.
The above referenced property is occupied by a tenant.
The above referenced property was occupied by tenant at the time the purchase contract
entered into with buyer, but now vacant.
The above referenced property is and was occupied by buyer at time the purchase contract
was entered into with buyer.
Other/Comments:
Seller (owner) OR Seller’s Designated Representative Printed Name
Date
