Alaska Landlord and Tenant Agreement

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Alaska Landlord and Tenant Agreement Powered By Docstoc

      Tanana Chiefs Conference
    Housing Services Department
     122 First Avenue, Suite 600
      Fairbanks, Alaska 99701
 Phone: (907) 452-8251, Ext. 3483
Toll Free: 1-800-478-6822, Ext. 3483
Fax: (907) 459-3851, Attn: Housing

                    TANANA CHIEFS CONFERENCE

Privacy Act Provisions                              Voluntary Disclosure

Under section 3(e)(3) of the Privacy Act 1974,      Your responses to the request for information
(5 USC 552a(e)(3)), each agency that                on the Weatherization Assistance Application,
maintains a system of records shall inform          Authorization for Release of Information
each individual from whom it solicits               form, and Fuel Information form are entirely
information of the authority which permits the      voluntary.
solicitation of the information; whether
disclosure is voluntary; the principal purpose      Principal Purpose of Information
for which the information is intended to be
used; the routine uses which may be made of         The information will be used by the local
the information; and the consequences, if any,      weatherization agency to implement the
resulting from failure by the individual to         weatherization program. It will be used by the
provide the requested information.         This     DOE and Alaska Housing Finance
statement is required by the Privacy Act to be      Corporation to monitor the effectiveness of
furnished prior to the collection and use of the    this program.
information requested on the application for
weatherization. You may retain this statement       Routine Uses
for your records.
                                                    The information which you provide may be
Program Authority                                   used in monitoring, evaluating, and planning
                                                    housing programs.        In addition, the
The specific authority for the maintenance of       information may be used in investigative,
weatherization client information is sections       enforcement or prosecutorial proceedings.
416 and 417 of the Energy Conservation and          Your application information is kept
Production Act, Pub. L. 94-385.         These       confidential.
sections direct the U.S. Department of Energy
(DOE), which is a sponsor of this program, to       Effects of Not Providing Information
monitor the effectiveness of this program and
to require a weatherization agency                  Should you decline to provide the information
implementing this program to keep records for       requested on the Application and forms, your
DOE monitoring.                                     dwelling    cannot     be   considered    for
                                                    weatherization assistance.
Alaska Housing Finance Corporation is the
recipient of weatherization funds from both
DOE and the State of Alaska Department of
Health and Social Services, and is required by
10 CFR 440 to document the eligibility of
every dwelling unit weatherized and to
maintain records for program monitoring and

WAP Subgrantee Operations Manual, Effective June 1, 1995                                     1-29
Number in household who are:               60 years of age or older               Native American            Handicapped

APPLICANT AFFIRMATION                                             inaccurate information has been provided to make eligible
                                                                  for this assistance. I will not be held liable for any injury or
I subscribe and affirm, under the penalties of law, that the      damage occurring on my property which is not a result of
statements made in this application for weatherization            my negligence or malfeasance certify that I have given my
assistance (including statements made in any accompanying         permission to allow work, monitoring of work on the
papers) have been examined by me and to the best of my            property listed in this application. I understand that it is the
knowledge and belief are true and correct. Prior to any           dwelling occupant and/or owner’s responsibility to discover
weatherization work, I agree to notify the agency of any          and correct unsafe or out-of-compliance conditions which
changes in the information in this application. I understand      exist apparent from the weatherization work.
that by signing this application, I consent to any other
inquiry to verify or confirm the information I have given.        I understand that this application for weatherization
                                                                  assistance does not guarantee that assistance will be granted
I certify that no household member holds a Temporary              but will be used in determining eligibility for the program.
Resident Status granted under section 245A or 210A of the         Whether or not an eligible applicant will be provided
Immigration and nationality Act as amended under the              assistance will depend in part upon the number of
Immigration and Control Act of 1986 (Public Law 99-603).          applications received, the remaining funds available and the
                                                                  priorities to be met by the program.
This assistance has no affect upon my social security, public
assistance, or any other income I have. The weatherization        I have read and understand the provisions of the Federal
work done will not obligate me financially and no lien or         Privacy Information Act.
mortgage will be held on the property, unless false or

Signature             X                                                           Date               ____________
Representative X                                                                  Date               ____________
Relationship                 _________________________________

                                         HOMEOWNER CERTIFICATION

I/WE,             _____________________________________________, certify that I/we am/are the owner(s) of

the property at           _______________________________________________________________________
(Print Address)        ___________________________________________________________________
Signature             X                                                           Date               _______________

 OWNERS VERIFIED THROUGH:              Examination of Deed                     LIST INCOME DOCUMENTATION ATTACHED:
                                       Confirmation by Tax Assessor’s Office
 Date:                                 Agency Signature

ORIGINAL to Agency          COPY to Applicant     RETURN APPLICATION TO:              TANANA CHIEFS CONFERENCE
                                                                                      122 First Avenue, Suite 600
                                                                                      Fairbanks, AK 99701

1299-94.2                                                                                                                       2
                               TANANA CHIEFS CONFERENCE

                               PERMISSION TO ENTER PREMISES

                                    TO THE BUILDING OWNER

Your building is being considered for weatherization services under the State of Alaska’s Enhanced
Weatherization (WX+) Program. This program is funded by the State of Alaska and the United States
Department of Health and Social Services and administered by the Tanana Chiefs Conference as the
agency serving your region.

The WX+ operates under the rules and regulations of both the United States Department of Energy’s
Low-income Weatherization Assistance Program (WAP) and the Alaska Department of Community and
Regional Affairs which have certain requirements of which you as building owner should be aware. At
the bottom of this page is a form granting permission for the responsible agency to enter your building to
collect eligibility documentation from your tenants and prepare a work plan.

If you want your building to receive the substantial improvements provided under the Enhanced
Weatherization Program, you are required to pay 50 percent of the cost of materials. Your agreement to
provide funding is not necessary until after the local agency has completed a work plan for your
building. At that time, you will be contacted by the agency to consider the planned work, your
estimated cost, and your willingness to pay your cost. If you prefer to finance your portion of the cost,
the agency may be able to assist you in locating lenders and applying for financial assistance. A copy of
the Owner Agreement is attached so that you may review it before meeting with the agency to consider

                               PERMISSION TO ENTER PREMISES

I, as owner/authorized agent for the building located at        _________________________ have read
and understand the above and hereby grant permission for representatives of Tanana Chiefs Conference
to enter this premises for the purposes of collecting eligibility documentation from the residents and
conducting a work plan which may include a blower door test, an infrared scan, testing of the air, and a
combustion test on heaters.

Name                                                                Date           ________________

Signature X

Agency Representative X                                             Date           _________________

Title            ______________________________________

1299-94.3                                                                                               3
                               TANANA CHIEFS CONFERENCE

               Alaska Weatherization Assistance Program Landlord – Tenant Policy
                          PERMISSION TO WEATHERIZE HOME

Applicable governing rules and regulations: 10 CFR 440.3, AS 34.03.010-380, Alaska Landlord –
Tenant Statutes.

Effective June 11, 1999.

A Weatherization Landlord – Tenant Permission to Enter Premises Agreement shall be signed in any
situation where a weatherization service provider plans to weatherize a rental dwelling unit. Prior to
conducting energy related building inspections and assessments, repairs and improvements,
weatherization service providers shall obtain written permission to enter the premises. The Landlord –
Tenant Agreement shall be signed prior to commencing weatherization activities. At least 24 hours
notice will be given to each tenant prior to assessing that unit.

If an agent acting on behalf of the owner of the property is to sign the agreement, that agent must show a
witnessed or notarized power of attorney authorizing that agent to enter into contractual agreements for
an owner.

A multi-family rental dwelling unit priority system shall be established by each agency as a part of the
regular client priority list. Priority will be given to buildings where elderly or disabled people reside, or
those dwelling which house families with children under six years of age. If a building with at least
50% of units housing those priority clients, the building will be a number one priority. If the building
houses 25% to 49% priority clients, it will be a number 2 priority, and if less than 25% are priority
clients, it will be a number three priority. Individual units may be served using the regular client priority

In all rental units, the weatherization service provider will determine the amount of materials needed to
weatherize the building. Service providers shall ask for cash or in-kind contributions from the
owner/agent. Whether or not a contribution is specified, weatherization work may precede.

For all units in a rental dwelling, the dollar amount of materials and labor provided by (the
Weatherization Service Provider) shall not exceed $(750) per unit, unless the owner is willing to
contribute cash or in-kind services. For any owner contributions, the weatherization agency will provide
up to $750 in materials and labor, and then match dollar for dollar any owner contribution, up to an
amount estimated by the weatherization assessor. If the landlord refuses to make a contribution, and the
job costs exceed the $750 estimated amount by less than 50% due to unexpected problems, no owner
contribution will be required, though the weatherization service provider may solicit one. If the owner
provides the materials as an in-kind contribution, weatherization crews may install those materials at the
going labor rate.

1299-94.4                                                                                                  4
On rental buildings of four-plex or less, or where tenants pay the heating fuel bills, the investment per
unit may be an amount specified by the weatherization service provider up to $1,200 without an owner
contribution. This amount shall be a part of the landlord tenant agreement, and be applied fairly and
equitably to all landlords.

Owners who qualify under the low income guidelines plus 20% can waive their contribution.

In-kind contributions or improvements may be counted in a similar manner as cash contributions. These
may include energy conservation or health and safety improvements to individual units, or to common
areas of the building. Only improvements made to the building in the six months immediately prior to
the date of applications may be counted as in-kind contributions. The Weatherization agency will
determine the value of improvements, using actual receipts for materials. Copies of all receipts should
be included in the client file. Weatherization service providers may create additional policies to count
non-cash contributions, so long as they are applied fairly and equitably to all landlords. These policies
may be subject to approval by AHFC program staff.

Improvements made by the owner should be made prior to the start of weatherization activities
whenever possible. If improvements must be made after Weatherization activities, the Weatherization
agency will insure they are completed.

All heating work will be included in the $750 on all rental units, if heating system service or repair costs
exceed $250.00 or need replacement, the owner must contribute 50% of the cost. The first $250, which
is not subject to the 50/50 match of landlord contributions, will count toward the $750 limit mentioned
in owner contributions above. All owner contributions for heating systems and weatherization activities
will be returned to the Weatherization Assistance Program, and shall not be used for other than
legitimate weatherization activities. Agencies may have the owner make the required contribution
directly to another contractor or materials supplier, provided they keep track of the transaction for
reporting purposes.

Only eligible weatherization measures shall be applied to any building, if the funds used to perform
those measures are funds provided by the Alaska Housing Finance Corporation (AHFC), and/or the
Department of Energy (DOE). No undue enhancement shall occur to the value of the dwelling units as a
result of weatherization work performed. Undue enhancement is defined as any enhancement to a
building that increases the value of the property, and does not provide energy conservation or health and
safety benefits to the tenant. If enhancements to the building can be shown to benefit a tenant, that
enhancement shall not be considered undue.

Commencing on the date this agreement is signed, and continuing for a period of eighteen months, the
building owner shall not terminate or evict any covered tenants or any subsequent tenants, provided the
tenant complies with all obligations owed to the owner in accordance with any leases or rental
agreements between the owner and tenants.

The agreement applies to present tenants and any subsequent tenants for the eighteen month period.

In addition to the provisions outlined above, all provisions of the Alaska Uniform Landlord and Tenant
Act (AS 34.03.010-380) apply to the owner and tenants who are parties to this agreement.

10 CFR 440.3(I) requires the benefits of weatherization assistance accrue primarily to the tenant, and not
to the landlord. Each agency should be prepared to show how weatherization has benefited the client of

1299-94.5                                                                                                 5
a rented dwelling, especially where the owner of the building pays the utilities. Agencies may use the
following form or develop some means of determining benefits to each tenant. Exit interviews
conducted during final inspections can assist an agency in determining benefits.

The agreement shall run with the land and/or weatherized unit in the case of sale or transfer to other
owner agents. A copy of this agreement shall be provided to the owner, tenant and Weatherization
provider’s client file.


I,       __________________ as the OWNER/AUTHORIZED AGENT for the building located at
       _____________________________, ALASKA, have read the above and hereby grant permission
for representatives of Tanana Chiefs Conference to perform necessary work on the house.

Name                                                             Date          ________________

Signature X

TCC Housing Representative X                                     Date          _________________

Title            ______________________

1299-94.6                                                                                           6
                                                TANANA CHIEFS CONFERENCE
                                           ALASKA HOUSING FINANCE CORPORATION
                                             Planning Department, Weatherization Section

                              WEATHERIZATION PROGRAM APPLICATION

A.    APPLICANT DATA:            Renter             Owner              Single Family         Multi-Family

      Mobile Home                                   Mobile Home Serial #

      NAME              ________________________ HOME TELEPHONE                 __________________

      RESIDENCE ADDRESS                    _________ WORK TELEPHONE             __________________

      MAILING ADDRESS                ___________ ZIP            ___    SSN      -        -


      1.     Elderly (60 years or older)                  3.     Native Americans
      2.     Disabled                                     4.     Other

B.    Has this home been weatherized at any prior time?

C.    ANNUAL INCOME: All income as listed in the State’s “Definition of Income” must be declared below:

        (List all permanent                  NAME                      AGE              ANNUAL AMOUNT
        residents residing                                                          $
        in this dwelling)








Please list all ages.
      TOTAL ANNUAL HOUSEHOLD INCOME $                          _____
      (Last 12 months from date of application)

1299-94.7                                                                                                   7

Permission is granted to perform weatherization work on my residence. I understand that funds for
weatherization assistance are being provided by the State of Alaska. As such the State may monitor
dwellings on a random basis for the sole purpose of determining that work was actually accomplished
and that program funds were properly expended. This monitoring does not include an inspection for or
in any way address compliance with fire, building, or any other safety codes. According to the terms of
the contract between State of Alaska and the Weatherization contractor, responsibility for weatherization
work performed on your dwelling must comply with existing applicable codes and/or manufacturers’
instructions as appropriate. The Weatherization contractor is solely responsible to assure this
compliance. This responsibility in no way extends to work or conditions not associated with the
performance of weatherization work. Accordingly, I understand that it is the dwelling occupant/owner’s
responsibility to discover and correct unsafe or out-of-compliance conditions which might otherwise

I further certify that all information furnished in support of this application is true and correct to the best
of my knowledge. I further certify that I meet the income guidelines of the Weatherization Program.
The number of permanent resident residing in my household is                  and the total annual household
income is $        _ .

I further certify that no household member listed in this application holds a Temporary Resident Status
granted under section 245A or 210A of the Immigration and Nationality Act as amended under the
Immigration and Control Act of 1986 (Public Law 99-603).

                                               ______________________________                         _______
Print Name                                     Signature                                       Date


1299-94.8                                                                                                    8
                                          ATTACHMENT “A”
                                      AHFC INCOME GUIDELINES
                                             FOR FY 2006

            Household Size           Income Limit            Household Size            Income Limit
                  1                     $24,354                    8                      $64,631
                  2                     $31,847                    9                      $66,036
                  3                     $39,341                   10                      $67,441
                  4                     $46,834                   11                      $68,846
                  5                     $54,327                   12                      $70,251
                  6                     $61,821                   13                      $71,656
                  7                     $63,226                   14                      $73,061

To be eligible for weatherization services the entire income for the family unit cannot exceed the published
income guidelines of Low Income Home Energy Assistance Program. The guidelines are based on income of
60% of the median income for the State of Alaska.

A family unit receiving cash assistance payments under Title IV (TANF), Low-Income Home Energy Assistance,
(LIHEAP) or Title XVI (SSI or APA) of the Social Security Act during the 12-month period preceding
application (AS 47.25, Articles 2 and 4) automatically meets the income eligibility requirements.

A full-time student away from home during the school year is consider “living together in the dwelling unit”.

A live-in-aide medically required by a member of a family unit is not considered a member of the family unit for
income purposes.

Family unit income is the total cash receipts before taxes (Gross Income) from all sources of the members of the
family unit. This includes the following:

   Alimony                                                     Rents (net rental income)
   Assistantships                                              Royalties (net)
   Cost-of-living allowance (COLA)                             Social security (no exemption for dependent
   Dividends including Alaska Permanent Fund                    students)
    dividends                                                   Strike benefits from union
   Fellowships                                                 Tips
   Government employee pensions                                Training stipends (net)
   Grant income                                                Unemployment compensation
   Interest                                                    Wages and salaries before any deductions
   Longevity bonus from State                                  Workers’ compensation
   Military family allotments                                  Veterans’ payments (no exemption for
   Net gambling or lottery winnings                             dependent students)
   Net receipts from self-employment (i.e., net                Veteran & disability payments
    business income)
   Overtime
   Periodic receipts from estates or trusts
   Private pensions
   Railroad retirement
   Regular insurance or annuity payments
   Regular support from an absent family member
    or someone not living in the family unit

1299-94.9                                                                                                       9
Income does not include the following:

   Assets drawn down such as a bank withdrawal
   Capital gains
   Dependent student income: Earnings of full-
    time high school students or post-secondary
    students enrolled for at leas 12 credit hours
   College scholarships
   Child support
   Dividends not exceeding $2,000 per individual
    from a Native corporation (Public Law 100-241)
   Federal non-cash benefits such as Medicare,
    Medicaid, Food Stamps, school lunches, and
    housing assistance
   Food or rent received in lieu of wages
   Gifts
   Grants or loans to a student
   JTPA payments
   LIHEAP payments
   Lump-sum inheritances
   Non-cash benefits such as employee fringe
   Deductions from wages to pay for health care
    benefits, if deducted by the employer
   One-time insurance payments
   Payment for foster children or foster care adults
   Sale of assets such as property, house, or vehicle
   Scholarships for college or university
   Tax refunds

1299-94.10                                               10
                        TANANA CHIEFS CONFERENCE

                         INCOME STATEMENT AFFIDAVIT

MY HOUSEHOLD WAS        ____________, AND DID NOT EXCEED     _________.


      EMPLOYER            EARNED BY                   DATE                AMOUNT


                                          Printed Name


1299-94.11                                                                         11
                                                 TANANA CHIEFS CONFERENCE
                                                      Housing Services Department
                                                       122 First Avenue, Suite 600
                                                            Fairbanks, 99701
                                                        (907) 452-8251, Ext. 3257

                           Bureau of Indian Affairs – Housing Improvement Program
                       Alaska Housing Finance Corp. – Enhanced Weatherization Program


I,      __________________ authorize the release of information requested by the Tanana Chiefs Conference –
Housing Services Department. This information shall be used solely for the purpose of assessment and
determination of clients eligibility and will not be released to any other person or agency outside of Tanana Chiefs
Conference, Inc.

State of Alaska:                                         United States Department of Human Services:
        Division of Public Assistance                           Supplemental Security Income
        Department of Employment                                Social Security Administration
        Division of Employment Insurance
        Department of Health & Social Services
        Division of Natural Resources (DNR)
        Longevity Bonus

Tanana Chiefs Conference:                                United States Department of the Interior:
      General Assistance Program                                Bureau of land Management (BLM)
      CCDBG-Child Care Assistance
      Tribal Work Experience Program                     Veteran’s Administration
      Energy Assistance Program

Doyon Limited                                            Alaska Railroad – Retirement

Yourself:                                                Spouse or significant other:
Employer:      ____________________                      Employer:       _________________
Address:     ______________________                      Address:      ___________________
City:     _________________________                      City:     _______________________

Other Income Source:     ___________                     Other Income Source:     _________
Address:      ______________________                     Address:      ____________________
City:     _________________________                      City:     _______________________

Retirement Income Source:    ________                    Pension Income Source:    ________
Address:      _______________________                    Address:      ____________________
City:     __________________________                     City:      _______________________

Signature:                                               Date Signed:        ____________

Printed Name:        __________________________          Social Security Number:         __________

1299-94.12                                                                                                       12
                               TANANA CHIEFS CONFERENCE
                                FUEL INFORMATION FORM
CLIENT NAME:           _________________________________
Type of primary heating system:     Oil          Natural Gas                            Electric
                                    Wood         Propane                                Other

Type of domestic hot water heater             Oil                Natural Gas            Electric
                                              Wood               Propane                Other
Is there an alternative supplementary heating source?                No        Yes, percent of time used    %
If yes, state type:      ___________
Last time heating system services:            _______          Estimated Annual Fuel Use:            gal.
Name and Address of service:            _____________                                       cords

Is this a business?       Yes           No
To: Fuel Supplier                     Mailing Address:

City:                                 AK      Zip Code                           Accounting Number

To: Fuel Supplier                     Mailing Address:

City:                                 AK      Zip Code                           Accounting Number

To: Fuel Supplier                     Mailing Address:

City:                                 AK      Zip Code                           Accounting Number

I hereby authorize you to release information on my fuel bills, both past and future, to the following
agency. I agree that a photocopy of this release may be used for the purpose stated.

                      Tanana Chiefs Conference
                      Housing Department
                      122 First Avenue, Suite 600
                      Fairbanks, AK 99701

I understand that this information will be used only to provide data for the above-named agency, and no
information obtained through this release shall be made public in such a manner that the dwelling or
occupants can be identified.
Fuel Customer Name                    Street Address/Mailing

City:                                 State                                      Zip Code

Signature         X                                                        Date
If possible, attach copies of fuel bills to this form.
1299-94.13                                                                                                  13

         _________________________ has applied for Housing Assistance under the
(applicant’s name)

Bureau of Indian Affairs – Housing Improvement Program or under the Alaska Housing Finance Corp.-

Enhanced Weatherization Program. In applying he/she have certified that they are the Homeowners of

record and own the land which the house sits on.

The legal property description for the lot on which the house sits is as follows: (include U.S. Survey

number, Lot, Block and Subdivision or Native Allotment number).



Homeownership and Land status is verified by the following records:

                     Council Land Records            City Land Records
                     TCC, Realty Records             State Records


I,     __________________________, acknowledge that the person named above is the homeowner
and owner of the land which the house sits on.

(Name of City or Tribal Government)                (Name of City or Tribal Government)

(Signature)                                        (Signature)

(Print Name/Title)                                 (Print Name/Title)

(Date)                                             (Date)

1299-94.14                                                                                         14

Description: Alaska Landlord and Tenant Agreement document sample