This is an official government website.
Here's how you know
Official websites use .govWebsite addresses ending in .gov belong to official government organizations in the United States.
Secure .gov websites use HTTPSA lock ( Lock ) or https:// means you've safely connected to the .gov website. Only share sensitive information on official, secure websites.
Seattle CiviForm
Note: Fields marked with a * are required.
I certify I have received and read a copy of Protect Your Family from Lead Based Paint. *
I received and read this document
The applicant specifically acknowledges(s) and agree(s) that:
I give the Seattle Office of Housing (City) permission to submit requests or release information to other non-profit organizations or government agencies for the purpose of providing assistance to me. Such information may include but is not limited my application, income and related documents, results of inspections conducted by the property rehabilitation specialist, the home repair scope of work and completed repairs. Such information may result in my receiving or being denied other City assistance. I authorize the City to enroll me in all City or King County assistance programs for which I am eligible.
You are hereby authorized to release to the City of Seattle, The Office of Housing (OH), and The Department of Human Services (DHS), any information which you may have in your files concerning the applicant, including, but not limited to: employment records, bank accounts, loan accounts, credit and financial reports, and mortgage and contract amounts.
Certification: I/We certify that the information provided in this application is true and correct as of the date set forth opposite my/our signature(s) on this application and acknowledge my/our understanding that any intentional or negligent misrepresentation(s) of the information contained in this application may result in civil liability and/or criminal penalties including, but not limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Section 1001, et seq. And liability for monetary damages to the Lender, its agents, successors and assigns, insurers and any other person who may suffer any loss due to reliance upon any misrepresentation which I/we have made in this application. *
Please enter the date you signed this form in the format month/day/year. *
If you included a second homeowner to this application, please have them sign their name and date on this form as well.
Please enter the date you signed this form in the format month/day/year.