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2. Section 1: Applicant Information
4. Nonprofit Organization Name*
6. Contact Person*
7. Contact Person Title*
9. Contact Phone Number*
10. Contact Email*
12. Mailing Address*
13. City*
15. State*
16. Zip Code*
17. Federal EIN (Employer Identification Number)*
21. Section 2: Project Information
23. Property Address*
25. City*
26. State*
27. Zip Code*
29. Homeowner Name*
30. Homeowner Email Address*
32. Homeowner Phone Number*
34. Assessed Value of Property*

    Upload evidence of property ownership and assessed value. 

36. Current Condition of Property*

    Brief description of deteriorated state, including photos if available. 

38. Condition of Property Photos
40. Proposed Scope of Work

    Attach detailed list of expenses, materials, and labor involved below. 

42. Exterior Improvements

    Siding, Roof, Windows, etc.

43. Interior Improvements

    Insulation, Electrical, Plumbing, etc.

44. Life Safety/Accessibility Upgrades
46. Total Project Cost*

    Upload estimated cost breakdown 

47. Grant Amount Requested (up to $25,000)*
51. Section 3: Eligibility
53. Is this property owner-occupied?*

    1. Yes
    2. No
55. Does this property fall within a neighborhood of high LMI (low-to-moderate income) concentration (Census Tracts 241.01 or 241.02)?*

    1. Yes
    2. No
57. Does the homeowner’s income fall within 100% of the Area Median Income (HUD definitions)?*

    1. Yes
    2. No
59. Upload income verification or certification from the homeowner

    i.e. paystubs, tax returns, award letters if SS or SSDI, pension award letters if VA, etc.

63. Section 4: Nonprofit Organization’s Financial Statement
65. Attach current financial statement (i.e. annual budget)*
69. Section 5: Administrative Costs
71. Are there any administrative costs associated with this project?*

    1. Yes
    2. No
73. If yes, please provide a detailed breakdown:

    (Limit of 5%)

77. Section 6: Project Timeline
79. Projected Start Date*
    Projected Start Date
80. Projected Completion Date*
    Projected Completion Date

    Must be within 1 year from the date of fund disbursement

82. Grant Reporting Requirement*

    1. I Agree

    By selecting the box above, you acknowledge a report on the use of funds must be submitted within 30 days of project completion.

86. Certification and Signature

    I hereby certify that the information provided in this application is true and accurate to the best of my knowledge, and that the nonprofit organization named above meets all eligibility requirements for the WEALTH Grant Program. By typing my name below, I acknowledge that this typed name serves as my electronic signature. 

88. Name*
89. Date*
    Date
91. Submission Instructions

    Completed applications along with required attachments should be submitted to:

    Attn: Community Development Office

    City of Waterville

    1 Common Street

    Waterville, ME 04901

    
    

    For any questions, please contact:

    Michael Hall

    Email: mhall@waterville-me.gov.

Leave This Blank:


93. 1. Receive an email copy of this form.
94. Email address

    This field is not part of the form submission.

95. Submit

* indicates a required field