City of Asheville Home Repair Program

City of Asheville Home Repair Program

Applicant Certification, Authorization & Disclosure
This form is used for the City of Asheville Home Repair Program. It contains the Applicant Certification & Authorization and Disclosure of Potential Conflicts of Interest.

Applicant Certification & Authorization
To the best of my knowledge and belief, all data provided in support of this application is true and complete, and is given for the sole purpose of obtaining a grant from the City of Asheville Home Repair program. The owner or governing board of my organization has authorized this application.
I acknowledge that my organization will adhere to the City of Asheville Home Repair Policy for program activities, and that awarded agencies will perform income qualification for selected homeowners.
I acknowledge that information supplied in this application may be checked by the City of Asheville to evaluate potential funding decisions. Verification may include obtaining credit reports, tax records, and eCourts documents to verify good standing for all collaborating organizations on the application. I acknowledge that this application is a public document and is subject to the Freedom of Information Act, North Carolina public records law, and other applicable laws.

Disclosure of Potential Conflicts of Interest
Are you, any of your employees, Board Members, business associates, or members of their immediate families:
Employees of, or closely related to, employees of the City’s Housing & Economic Development Department?
Members of, or closely related to, members of Asheville City Council or a candidate for election to City Council?
If you have answered YES to any of the above questions, please include a full explanation. The existence of a potential conflict of interest does not necessarily make your project ineligible for funding, but an undisclosed conflict may result in the termination of any assistance and immediate repayment of the grant.

Declaration
I certify that the information provided on this form is true, complete, and accurate to the best of my knowledge. By checking this box and typing my full name below, I am providing my electronic signature.
Organization
Title of Applicant
Full Legal Name of Applicant
(Required for Signature)
Date Signed

MonthDayYear
Email of Applicant
example@example.com
Should be Empty:

Applicant Certification & Authorization