2005 AGN SEP 06 I26 - Laserfiche WebLink

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EXHIBIT C Rancho Mill Home Beautification Grant Program Application Applicant Information Applicant Name iRh OR'A IEV Property Address Phone # Account # Mailing Address City, State, Zip Home phone # Daytime phone # # of Household Members* *Household Members include: 1) family members living in the home, 2) family members who do not live in the home, but are primarily supported by the Applicant and 3) non -family members who live in the home. 1. Is the property your principal residence? ❑ Yes ❑ No 2. Are you the homeowner? ❑ Yes ❑ No 3. Is the property a single family residence? ❑ Yes ❑ No State Law requires that your household income not exceed 120% of the median income in order to receive the grant assistance. Please complete th following for your household and provide copies of your past 2 Gross Monthly Income years' W -2s, income tax returns and most recent paycheck stubs covering the last 30 days. 1. Applicant's Monthly Income 2. Monthly Income from all other Household Members* 3. Other Income Total Gross Monthly Household Income (add 1-3) (includes Wage or salary, overtime, commissions, fees, tips, bonuses, part-time employment, Social Security/Disability) (includes Wage or salary, overtime, commissions, fees, tips, bonuses, part-time employment, Social Security/Disability) (includes rental income, interest & dividends, alimony/child support, armed forces allowance & public assistance) Please indicate sources of other income: The Grant Program requires that you contribute $1 for every $2 (up to $2,000) that the Agency is granting. Please indicate that you have the funds by completing the worksheet below and by providing copies of those Banking Information bank statements. Name of Bank Address Phone # Account # Balance ❑ Checking ❑ Savings Name of Bank Address Phone # Account # Balance ❑ Checking ❑ Savings Name of Bank Address Phone # Account # Balance ❑ Checking ❑ Savings Name of Bank Address Phone # Account # Balance ❑ Checking ❑ Savings 8/30/2005