information and you have made this application in person, under federal regulations the lender is required to note ethnicity, race, and sex on the basis of visual observation or surname. If you do not wish to furnish the information, please check below. APPLICANT: CO-APPLICANT: __ I do not wish to furnish this information __ I do not wish to furnish this information Ethnicity: Ethnicity: □ Hispanic or Latino □ Hispanic or Latino □ Not Hispanic or Latino □ Not Hispanic or Latino Race: Race: □ American Indian or Native □ American Indian or Native □ Asian □ Asian □ Black or African American □ Black or African American □ Native Hawaiian or Other Pacific Islander □ Native Hawaiian or Other Pacific Islander □ White □ White Sex: Sex: □ Female □ Female □ Male □ Male Important – Please Read Fair CrEdit Reporting/employment disclosure Any consumer reporting agency is hereby authorized and instructed to compile and furnish to Dollar Bank a credit report to be used in connection with this credit application. Dollar Bank is also authorized to verify my employment history. MORTGAGE APPLICATION DISCLOSURE (REAL ESTATE SECURED LOANS ONLY) This loan will be secured by a mortgage or a deed of trust. You acknowledge that this property will not be used for any illegal or restricted purpose. FALSE STATEMENT Please be on notice that it may be a federal crime to knowingly make any false statements concerning this loan application. I/We certify that the information provided in this application is true and correct as of the date set forth opposite my/our signatures below. ___________________________________________ Date: ____/____/____ Borrower’s Signature ___________________________________________ Date: ____/____/____ Co- Borrower’s Signature
PARTICIPATION REQUEST FOR LEAD HAZARD REDUCTION GRANT To: Urban Redevelopment Authority Pittsburgh From: Name: ______________________________________ The undersigned hereby request participation under the Lead Hazard Reduction Grant Program with respect to the property located at _______________________________________, in the ________ Ward of the City of . The above property was constructed before 1978, and there may be a possibility of lead based paint. The undersigned acknowledge that the Urban Redevelopment Authority of Pittsburgh will provide a grant covering 25% of the total cost up to $10,000 of lead hazard reduction work to be performed at the above address according to a Risk Assessment, which will be performed once my application is approved and referred to the Urban Redevelopment Authority. I also acknowledge that there is a $300.00 Lead Fee, which will be included as part of the grant for the lead hazard reduction work. I also understand that if there is any lead hazard reduction work to be done, it must be performed by a contractor who is certified to do lead reduction work. I/We hereby authorize the Urban Redevelopment Authority of Pittsburgh, its employees or its designated agent, to enter upon the above premises for the purpose of inspecting the property and preparing the specifications for lead hazard reduction and any required associated rehabilitation of the structure. _______________________________ ________________________ Borrower Date _______________________________ ________________________ Co-Borrower Date NOTIFICATION Watch Out for Lead-Based Paint Poisoning