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Attachment 1 <br /> ORANGE COUNTY n400CHCD <br /> NORTH CAROLINA ORANGE COUNTY HOUSING&(OMMUNITY DEVELOPMENT <br /> LONG TIME HOMEOWNER ASSISTANCE PROGRAM <br /> "PLEASE ENSURE ENTIRE APPLICATION IS COMPLETE BEFORE SUBMITTING" <br /> HOMEOWNER NAME: DATE: <br /> HOMEOWNER PHONE NUMBER AND EMAIL: <br /> NUMBER OF ADULTS IN HOUSEHOLD: <br /> NUMBER OF CHILDREN IN HOUSEHOLD: <br /> ADDRESS OF PROPERTY: <br /> HAVE YOU OWNED THE PROPERTY AND HAS IT BEEN YOUR PRIMARY RESIDENCE FOR <br /> THE LAST 10 YEARS? ❑ Yes ❑ No <br /> DID YOUR PROPERTY TAXES INCREASE THIS YEAR (2021)? ❑ Yes ❑ No ❑ Unsure <br /> Household Size <br /> 1 2 3 4 5 6 7 = 8 <br /> 80%AMI 1 $48,400 1 $55,300 $62,200 $69,100 $74,650 $80,200 $85,700 1 $91,250 <br /> Source:2021 HUD Income Limits <br /> GROSS ANNUAL HOUSEHOLD INCOME <br /> Assistance is available to Orange County households earning no more than 80%of the area median income(AMI). <br /> GENDER OF HOMEOWNER: ❑ Male ❑ Female ❑ Nonbinary <br /> RACE OF HOMFOWNER: <br /> DATA WILL BE USED FOR ONGOING RACIAL EQUITY ANALYSES TO IMPROVE PROGRAM DELIVERY <br /> ❑ White ❑ Black/African American ❑ Asian ❑ American Indian/Alaskan Native <br /> ❑ Native Hawaiian/Other Pacific Islander ❑ Other-Multi Racial <br /> ETHNICITY OF HOMEOWNER: <br /> Hispanic or Latinx? ❑ Yes ❑ No <br /> HOW WERE YOU REFERRED TO THIS PROGRAM? ❑ HousingHelpline ❑ Agencyreferral <br /> REFERRING AGENCY (IF APPLICABLE): <br /> Mailing Address Again Office Satellite Office <br /> P0.Box 8181 300 W.Tryon Street 2501 Homestead Road <br /> Hillsborough,NC 27278 Hillsborough,NC 27278 Chapel Hill,NC 27516 <br /> Telephone(919)245-2490• Fax(919)644-3056•T00(919)644-3045 <br />