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Home My WebLink AboutForm B - Lead Supporting DocsPage | 1 Need help? Contact Daniela Bautista-Amick dbautista-amick@southbendin.gov or 574-245- 6085 South Bend Lead Protection Program FORM B – Supporting documents for About me Supporting documents Directions 1 Check all statements that apply to you. 2 Check the documents you need to submit. We accept photos (one-page documents only), electronic, and paper copies. 3 Read directions for gathering the right documents. Income from employment documents If you don’t file taxes or report earnings to the government, you are not eligible for the program because your income cannot be verified. About me Supporting documents Directions  I worked consistently for the past 2 months.  All pay stubs from the past 2 months If you are paid bi-weekly: • Provide 5 most recent paystubs If you are paid weekly: • Provide 9 most recent paystubs If you do not have traditional paystubs: • Provide other documents showing income from the past 2 months  I worked  All pay stubs from the past 12 months. If you do not have traditional paystubs: inconsistently for • Provide other documents showing example, seasonal income from the past 12 months work) in the past 12 months.  I own my own business or am self- employed.  Form 1040, Schedule C Federal tax return  Verification of Income from Business form  Federal and State tax returns from past 2 years (2022 and 2023)  W-2’s from past 2 years (2022 and 2023  Copy of earnings from Social Security Administration Your income needs to be the same in each document. Please submit all documents. Continue to next page  FORM B South Bend Lead Protection Program Page | 2 Need help? Contact Daniela Bautista-Amick dbautista-amick@southbendin.gov or 574-245- 6085 Income from other sources documents  FORM B – Supporting documents for About me Supporting documents Directions 1 Check all statements that apply to you. 2 Check the documents you need to submit. We accept photos (one-page documents only), electronic, and paper copies. 3 Read directions for gathering the right documents. About me Supporting documents Directions  I have other forms of income.  All documents showing other forms of income such as: • Child support • Social Security Income (SSI) • Social Security Disability Income (SSDI) • Adoption subsidy • Pension • Alimony • Other (Rental Income) If you receive child support: • Provide document showing last 12 months of payments If you receive Social Security Income (SSI) or Social Security Disability Income (SSDI): • Provide annual benefits letter for the current year If you receive adoption subsidies: • Provide agreement document showing monthly subsidy amount If you receive other forms of income: • Provide documents showing other forms of income  I do not have income.  Sign Zero Income Form (Form C) If you have no forms of income, you need to confirm that. Continue to next page  South Bend Lead Protection Program FORM B – Supporting documents for Need help? Contact Daniela Bautista-Amick dbautista-amick@southbendin.gov or 574-245- 6085 Page | 3 About me Supporting documents Directions 1 Check all statements that apply to you. 2 Check the documents you need to submit. We accept photos (one-page documents only), electronic, and paper copies. 3 Read directions for gathering the right documents. Bank statements and assets documents About me Supporting documents Directions  I have a checking account.  6 most recent checking account statements The statements must include the name of the financial institution, all pages, your name, account number, balance sheet, and detail of transaction.  I have a savings account.  Most recent savings account statement The statement must include the name of the financial institution, all pages, your name, account number, balance sheet, and detail of transaction.  I have assets other than money in banks.  2 most recent statements for each asset such as: • Other savings • Investments • Retirement • Stocks Statements might be provided monthly, quarterly, or yearly. Provide 2 most recent statements no matter how often you get them.  I do not have a bank account or assets.  Required documents pending contact with Daniela Bautista-Amick Contact Daniela Bautista-Amick at 574-245-6085 to figure out a way to show this in your file. Continue to next page  South Bend Lead Protection Program FORM B – Supporting documents for Need help? Contact Daniela Bautista-Amick dbautista-amick@southbendin.gov or 574-245- 6085 Page | 4 About me Supporting documents Directions 1 Check all statements that apply to you. 2 Check the documents you need to submit. We accept photos (one-page documents only), electronic, and paper copies. 3 Read directions for gathering the right documents. Property ownership documents About me Supporting documents Directions  I own the home,  Copy of recorded deed  Declaration page of current home insurance  Proof of current paid taxes (tax statement)  Copy of certificate of incorporation with name of applicant (ONLY if you own your property as a company) You can get the copy of recorded deed from the St. Joseph County Recorder’s Office. You can get the proof of current taxes from the St. Joseph County Treasurers Office. If you own your property as a company, you must provide a legal document showing you can sign the application for the company (ex: Joe can sign on behalf of Alpha Properties).  I am under a land contract, and the deed is not in my name. I am renting to own. OR  I am the tenant. I am not renting to own.  Copy of recorded deed  Declaration page of current home insurance  Proof of current paid taxes (tax statement) You may not have all of these documents. The property owner may provide the documents directly to Daniela Bautista-Amick at dbautista- amick@southbendin.gov or contact her at 574-245-6085. You and the property owner must sign the application. Continue to next page  and the deed is in my name. South Bend Lead Protection Program FORM B – Supporting documents for Need help? Contact Daniela Bautista-Amick dbautista-amick@southbendin.gov or 574-245- 6085 Page | 5 About me Supporting documents Directions 1 Check all statements that apply to you. 2 Check the documents you need to submit. We accept photos (one-page documents only), electronic, and paper copies. 3 Read directions for gathering the right documents. Rental assistance documents About me Supporting documents Directions  I am the tenant, and I receive a tenant- based Section 8 voucher.  Copy of Housing Assistance Payment (HAP) contract  Current HAP amendment with rental assistance amount If you do not receive a Section 8 voucher for rental assistance, you do not need to provide additional documents.  I am the tenant, and I receive a project- based Section 8 voucher.  Copy of current HUD form 50059 with rental assistance amount If you do not receive a Section 8 voucher for rental assistance, you do not need to provide additional documents.  I do not receive a Section 8 voucher.  None None Continue to next page  South Bend Lead Protection Program FORM B – Supporting documents for Need help? Contact Daniela Bautista-Amick dbautista-amick@southbendin.gov or 574-245- 6085 Page | 6 4 Gather and submit the documents to Daniela Bautista-Amick, Department of Community Investment. • Submit photos of one-page documents only (Examples: Driver’s licenses, income benefit statements, tax statements, insurance declarations, etc.) to dbautista- amick@southbendin.gov • Submit electronic copies to dbautista-amick@southbendin.gov • Submit paper copies by scheduling an in-person appointment or mail (Daniela Bautista- Amick, 227 W JEFFERSON BLVD, STE 1300S SOUTH BEND IN, 46601) About me Supporting documents Directions 1 Check all statements that apply to you. 2 Check the documents you need to submit. We accept photos (one-page documents only), electronic, and paper copies. 3 Read directions for gathering the right documents. Name change documents About me Supporting documents Directions  My legal name is different from the name on the documents I will provide.  Copy of legal and recorded name change document such as: • Marriage license • Divorce decree • Other legal or court document showing name change Provide one of these documents if your name is different on any of the documents you will provide.  My legal name is the same name on the documents I will provide.  None None You’re done submitting supporting documents!