Agreement - Indiana Housing and Community Development Authority - Supplemental Disaster Recovery- Owner Occupied Rehab for Lead

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I/We, Appendix A Duplication of Benefits Affidavit ("Affidavit") affirm the following: I/We own real property at (City/Town), Indiana (the "Residence") which is located in an area that was impacted by the floods of2008. I/We is/are executing this Affidavit in connection with the rehabilitation of the Residence by �. (Organization) through a homeowner rehabilitation project funded under the Indiana Housing and Community Development Authority's ("IHCDA's") Weatherization Owner -Occupied Rehabilitation Program (the "Program"). 3. In addition, UWe have received or will receive the following amounts and types of assistance from the sources listed below ("Duplicative Assistance") for the rehabilitation of the Residence, structural repair of the Residence or replacement housing: a. Insurance (Flood Insurance, Homeowner's, etc.) $ b. Federal Emergency Management Agency (FEMA) c. Small Business Administration (SBA) Loan $ d. The American Red Cross (Red Cross) $ e. Other agencies (besides IHCDA) $ _ 4. I/We have received no other assistance funds in the for rehabilitation of the Residence, structural repair of the Residence or replacement housing other than that set forth above in paragraph 4. 5. 42 U.S.C. 5155(a) prohibits federal agencies from providing assistance to any person for "any part of such loss" as to which he has received financial assistance under any other program or from insurance or any other source ( such as, FEMA, SBA, Insurance, etc.). 6. I/We understand that the amount of assistance received by I/We from IHCDA must be reduced by the amount of Duplicative Assistance received or will be received for rehabilitation of the Residence, structural repair of the Residence or replacement housing, from other sources (such as, FEMA, SBA, the Red Cross, homeowner's insurance, etc.) for the same purpose. 7. Therefore, I/We understand that if I/We receive assistance from a source other than IHCDA (such as, FEMA, SBA, the Red Cross, homeowner's insurance, etc.) for the rehabilitation of the Residence, structural repair of the Residence or replacement housing, I/We must repay the assistance received from IHCDA. 8. I/We certify under State and Federal penalties for perjury and fraud that the information provided above is true and accurate and acknowledge that repayment of all assistance received by Me/Us from IHCDA, payment of fines and/or imprisonment may be required in the event that I/We provide false, incomplete or misleading information in this Affidavit or during the rest of this process. Property Owner Signature of Property Owner Date Property Owner Signature of Property Owner Date CDBG-D C1TY OF SOUTH BEND DR20t- 018-003 Recapture Page 24 of 24