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Unit Closeout Report - Department for Local Government by shuifanglj

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									                                       NSP Homebuyer Unit Completion Packet
                            NSP Subgrantee:
   Funding agreement number:                                           Household first/last name:
                                Unit address:                                                                       City:
                                      ZIP+4:                                                                   County:

                                      Final draw for administrative funds/developer fee and project costs. Note: Final 10% of funds cannot be
                      Attached
                                      drawn until unit completion report is submitted and approved. - Draw requires signature, attach to
                       Sent prev.     packet.
       Yes                 No         Are all inspection issues cleared (if an inspected unit)? If no, contact DLG.

                                           Attached           Sent previously     Date of appraisal:                        Valuation:
        Final appraisal
                                      Date of buyer's fully-executed purchase contract (must be within 180 days of
                                      appraisal):
    Homebuyer information                  Homebuyer ed certificate from HUD-approved agency                       Household AMI:

                                        Good Faith Estimates (all loans to buyer); are ALL LOANS fixed-rate and                          Yes       No
                           Attached
                                        fully amortizing? (i.e., no balloon loans, due at maturity, etc.)
                           Attached     Signed HUD-1 Settlement Statements (one for each source of financing)
                           Attached     Executed NSP promissory note
Loan closing
                           Attached     Recorded NSP mortgage
  and loan
  servicing                Attached     Floodplain Certification
 documents
                                        Declaration page of homeowner's insurance with your organization as loss payee; insurance value must
                           Attached
                                        be equal or greater than sum of all secured funds.
                           Attached     Loan closing cover sheet (tab 4 in this worksheet)
                                        If buyer's first payment in less than 30 days from closing, provide buyer with temporary payment coupons
                           Attached
                                        (tab 5 in this worksheet)

                                            Total buyer down payment required:                                              NSP amt:

    Uses of NSP for buyer                                                                                                   NSP
    permanent financing                  NSP settlement charges (closing costs)                                             principal
                                                             on buyer's behalf:                                             reduction
                                         Total NSP permanent investment (to buyer):                    $0.00
                 NSP lien position:          1st                 2nd             3rd (prior written approval required)

  Length of affordability period:                                               (years)
     Escrows to be handled by:               1st mortgage lender (name):                                                                  KHC on behalf of DLG

                     Escrow funds           If DLG, escrow check attached (payable to Kentucky Housing Corporation) for

                                        If NSP was used for acquisition/development and was taken out by other permanent financing, attach
                                        check for amount of program income (payable to the Kentucky State Treasurer; please put unit address
       Program income                   and your agency name on memo line).
                                           Amount of program income check:

                                                   Attached       Lease-purchase tenancy agreement
  Lease-Purchase Programs                          Attached       Purchase contract
                                             Maximum occupancy period prior to purchase:

Household characteristics (drop-        No. of persons in household:                                 Household type:
        down menus)
                                      Ethnicity:                                                                            Hispanic?

                           Attached   Final Use of Funds Expenditure Statement (tab 2 in this workbook)
 Other cross-
  cutting or
administrative
 Other cross-            Attached   Minority/Women Business Enterprise (MBE/WBE) Form (tabs 5-6 in this workbook)
  cutting or
                         Attached   Final Photo - please email gif, jpeg or other electronic photo with completion packet.
administrative
                                    Lead-Based Paint Completion Packet, including Section I or Section II, if applicable (tabs 7-10 in this
                         Attached   workbook)
If the cost has changed, by signing below, you certify that the maximum sales price for the home does not exceed the following:
                 $150,000-Households at 80% or below of area median income
                 $237,000-Households at 80.1% to 120% of area median income


                   Signature:
                 $150,000-Households at 80% or below of area median income                   Date:
                 $237,000-Households at 80.1% to 120% of area median income
                                                  Final Uses/Expenditures of Funds
                                                                                       Funding
      Subgrantee: 0                                                              agreement no.:   0
Household name: 0
     Unit address: 0                                                                      City:   0
             State:    KY     ZIP+4:         00000-0000

Unit produced under Eligible Use(s):             A               C           E
                                                 B               D

                                                                Eligible Use A - acquistion only
                                                                                                       Non-NSP
                                                                                                      permanent                          Name of other funding
                                                                                 NSP only              financing        TOTALS                 source
     Closing cost assistance (Pg 2 of HUD-1 Settlement Statement)                           $0                     $0               $0
     Maximum of 50% of lender-required down payment:                                        $0                     $0               $0
     Principal write-down assistance                                                        $0                     $0               $0
     Other disposition:                                                                     $0                     $0               $0
     Other:                                                                                 $0                     $0               $0
                                                                                    Total unit acquisition cost                     $0

                                                      Eligible Uses B, C, D, E - During Development
                                                                                                  Second eligible
                                                                                                    use if more         Non-NSP
                                                                             Put eligible use     than one (i.e., D       interim        Name of other funding
                         Development funding                                       here               and E)            financing              source
1    Appraisal (project delivery cost)                                                      $0                     $0               $0
2    Boundary survey (project delivery cost)                                                $0                     $0               $0
3    Title search (project delivery cost)                                                   $0                     $0               $0
4    Initial inspection (delivery cost)                                                     $0                     $0               $0
5    Site-specific ERR checklist if applicable (project delivery cost)                      $0                     $0               $0
6    Attorney/notary etc. at acquisition                                                    $0                     $0               $0
7    Acquisition                                                                            $0                     $0               $0
8    Property insurance (hazard, flood) during development                                  $0                     $0               $0
9    Work write-ups/bid specs if applicable (project delivery cost)                         $0                     $0               $0
10   Architectural                                                                          $0                     $0               $0
11   Engineering                                                                            $0                     $0               $0
12   Relocation (if applicable)                                                             $0                $0           $0
13   Homebuyer education for purchasing household (delivery cost)                           $0                $0           $0
14   Demolition (if applicable)                                                             $0                $0           $0
15   Site preparation                                                                       $0                $0           $0
16   Lead hazard evaluation costs                                                           $0                $0           $0
17   Rehab hard costs related to lead-based paint reduction                                 $0                $0           $0
18   Rehabilitation costs unrelated to lead-based paint (if applicable)                     $0                $0           $0
19   New construction (on demolished or vacant property only)                               $0                $0           $0
20   Construction inspections (if by staff, project delivery cost)                          $0                $0           $0
21   Developer fee (if applicable), 15% of non-staff development cost                       $0                $0           $0
22   Holding costs/temporary property maintenance                                           $0                $0           $0
23   External costs related to sale of property (delivery cost)                             $0                $0           $0
24   Loan processing costs if applicable (delivery cost)                                    $0                $0           $0
25   Davis-Bacon wage rate compliance (delivery cost) if applicable                         $0                $0           $0
26   Other project costs (detail):                                                          $0                $0           $0
27   Other project costs (detail):                                                          $0                $0           $0
28   Other project costs (detail):                                                          $0                $0           $0
                                  TOTAL DEVELOPMENT FINANCING                               $0                $0           $0   $0

                                                  Eligible Uses B, C, D, E - Permanent Financing
29 NSP development financing rolled to permanent financing for homebuyer assistance
   a Closing cost/settlement charges assistance (from checklist)                $0
   e Maximum of 50% of lender-required down payment:                            $0
   d Principal write-down assistance                                            $0
30 Non-NSP permanent financing
   a Source 1                                                                   $0                Loan             Grant
     b   Source 2                                                                           $0    Loan             Grant

     c   Source 3                                                                           $0    Loan             Grant

31                              TOTAL TRANSACTION AMOUNT                                    $0
   Was any portion of the non-NSP funding used during development and rolled to
                                                                                            Yes          No
32 permanent financing?
   If yes on any above sources, total amount of interim rolling to permanent (so we don't
33 count the same leverage twice!):                                                               $0.00
                                                   Single-Family Loan Servicing Set-Up Form
                                                    Kentucky Neighborhood Stabilization program
                                                     (To Be Completed by Agency for Loan Set-Up)
NSP AMOUNT SECURED                  $0.00                                 SUBGRANTEE                     0
                                                                          CONTACT PERSON
BORROWER                                                                  MAILING ADDRESS
SS#                                                                       CITY, KY, ZIP
MAILING ADDRESS                                                           PHONE
CITY, KY, ZIP                                                                COMPLETE ESCROW INFO ONLY IF DLG/KHC SERVICING!!
PHONE                                                                     TAX/INSURANCE ESCROW               YES      NO

                                                                          HAZARD INSURANCE                   YES      NO

CO-BORROWER                                                               HAZARD INSURANCE NAME
SS#                                                                       ANNUAL AMOUNT
MAILING ADDRESS                                                           FLOOD INSURANCE                    YES      NO

CITY, KY, ZIP                                                             FLOOD INSURANCE NAME
PHONE                                                                     ANNUAL AMOUNT
PROPERTY ADDRESS                    0                                     COUNTY TAX                         YES      NO

CITY, KY, ZIP                                                             COUNTY NAME
                                                                          COUNTY TAX ID
      NSP amortizing and forgivable loan information                      ANNUAL AMOUNT
                                                                          CITY TAX                           YES      NO

% RATE                                                                    CITY NAME
TERM IN MONTHS                                                            CITY TAX ID
TOTAL LOAN AMOUNT                                                         ANNUAL AMOUNT
TOTAL REPAYABLE AMT                                                       SCHOOL TAX                         YES      NO

MONTHLY MORTGAGE AMT                                                      SCHOOL NAME
FIRST PAYMENT DUE DATE                                                    SCHOOL TAX ID
FORGIVABLE AMT                                                            ANNUAL AMOUNT
TERMS OF FORGIVE AMT                                                      SEWER                              YES      NO

CLOSING DATE                                                              REPORT CREDIT BUREAU               YES      NO

MATURITY DATE                                                             1st MORTGAGE LENDER
SERVICING ATTACHMENTS              (copies only)                          MAILING ADDRESS
      PROMISSORY NOTE                                                     CITY, KY, ZIP
      RECORDED MORTGAGE                    DECLARATION INSURANCE          PHONE
      COPY OF LAST PAID TAX BILL             WITH PAID RECEIPT            CONTACT PERSON
      AMENDMENTS/MODIFICATIONS             FLOOD INSURANCE                EMAIL ADDRESS
                                             WITH PAID RECEIPT            PHONE
2nd MORTGAGE LENDER                                                       3rd MORTGAGE LENDER
MAILING ADDRESS                                                           MAILING ADDRESS
CITY, KY, ZIP                                                             CITY, KY, ZIP
PHONE                                                                     PHONE
CONTACT PERSON                                                            CONTACT PERSON
EMAIL ADDRESS                                                             EMAIL ADDRESS
PHONE                                                                     PHONE
NOTES                                                                                              FOR KHC USE ONLY
                                                                          INVESTOR GROUP #               COMMENTS:
                                                                          BANK CODE #
                                                                          GROUP CODE #
                                                                          (Assigned by KHC Only)

                                                                                                             YES      NO
MEMO FICS REGARDING   YES   NO
      Neighborhood Stabilization Program (NSP) Mortgage Loan
                  TEMPORARY Payment Coupon
Note: The Department for Local Government contracts with Kentucky Housing Corporation for loan
servicing. DLG provides information from your completion report to KHC. If the homebuyers' first
payment date is less than 30 days from closing, please provide the buyer with these temporary
payment coupons . Payment should be payable to Kentucky Housing Corporation and include the
borrower name and unit address on the memo line, and should be sent to DLG with the unit completion
report package. Print additional coupons as needed.


                       Loan Number                                   Due Date             Total Payment




                                     If Received After              Late Charge            Late Payment


                                 UNDESIGNATED FUNDS WILL BE APPLIED TO ESCROW AND OUTSTANDING FEES.

AVOID LATE CHARGES. MAKE YOUR PAYMENT ON THE DUE DATE.

Laura Kronauer
                                                              ADD'L ESCROW
Neighborhood Stabilization Program
Kentucky Department for Local Government                      LATE CHARGES
1024 Capital Center Dr., Ste. 340
Frankfort, KY 40601                                           TOTAL REMITTED


                                     PAYMENT INSTRUCTIONS
When making your monthly payment, please be sure to:
 Enclose the proper coupon.
 Make check payable to Kentucky Housing Corporation.
 Do not send cash.
 Please allow sufficient time for mail delivery and posting to avoid late charges. Postal delays do not
  excuse late charges. Any payment received after the late payment date shown will be assessed a
  late charge.
 If additional funds are included in excess of your required monthly payment, please specify the
  purpose of the excess funds in the Payment Distribution section on the coupon; otherwise, the
  additional funds will be applied to: 1) delinquent late charges; 2) escrow.
 Partial payments are not acceptable.

          For questions or concerns, please call the Kentucky Department for Local Government
               NSP Financial Advisor, Laura Kronauer, at 1-800-346-5606, extension 291.
                                  PROJECT PERFORMANCE REPORT FOR CONSTRUCTION/REHAB
                                                                                                                         Page 1 of 2
                                  MINORITY BUSINESS ENTERPRISES AND WOMEN ENTERPRISES


In the table below, enter the number and dollar value of contracts for the HOME-assisted project. Enter whole numbers only.
Note: The total number and dollar amount of contracts and subcontracts under "MBE" must equal the total under "WBE".
                                   a. Total       b. Alaskan Native or   c. Asian or Pacific   d. Black     e. Hispanic   f. White
             MBE                                     American Indian                Islander          Non-Hispanic        Non-Hispanic
            Contracts

1. Number                             0                      0                          0                  0         0           0

2. Dollar Amount                      0                      0                          0                  0         0           0
         Subcontracts

1. Number                             0                      0                          0                  0         0           0

2. Dollar Amount                      0                      0                          0                  0         0           0

                                  a. Total          b. Women Business               c. Male
             WBE                                     Enterprises (WBE)
            Contracts

1. Number                             0                      0                          0

2. Dollar Amount                      0                      0                          0
         Subcontracts

1. Number                             0                      0                          0

2. Dollar Amount                      0                      0                          0

                                                                  Minority/Women Contractor Name
Recipient: #REF!                                                    (attach list if more than one):

Owner Name: #REF!

Project Address: #REF!                                           Address:

City:              #REF!                     Zip:    #REF!       Tax Identification Number:
                                                       PROJECT PERFORMANCE REPORT
                                                                                                                                      Page 2 of 2
                                                    MINORITY OWNERS OF RENTAL PROPERTY

 In the table below, enter the number of NSP-assisted rental property owners and dollar value of NSP-assisted rental properties during
 the reporting period.
MINORITY OWNERS OF               a. Total        b. Alaskan Native or       c. Asian or Pacific      d. Black        e. Hispanic         f. White
REAL PROPERTY                                      American Indian               Islander          Non-Hispanic                        Non-Hispanic

 1. Number                                0                         0                  0                    0                0                      0
 2. Dollar Amount                        $0                         $0                 $0                  $0               $0                  $0

                                                   RELOCATION AND REAL PROPERTY ACQUISITION

 In the table below, enter the number of parcels acquired, the acquisition cost of the parcels acquired, persons displaced and cost of relocation
 payments.
RELOCATION AND ACQUISITION                                                                  a. Number                                b. Cost
1. Parcels Acquired                                                                              0                                      0

2. Businesses Displaced                                                                          0                                      0

3. Nonprofit Organizations Displaced                                                             0                                      0

4. Persons Temporarily Relocated, not Displaced (# of Households)                                0                                      0



                                       a. Total         b. Alaskan Native or   c. Asian or Pacific     d. Black        e. Hispanic            f. White
 PERSONS DISPLACED                                        American Indian           Islander         Non-Hispanic                           Non-Hispanic
 # of Persons Displaced                   0                          0                  0                   0                0                   0
 (# of Households)                        0                          0                  0                   0                0                   0
 6. Cost of Persons Displaced            $0                         $0                 $0                  $0               $0                  $0
        Home Buyer Lead-Based Paint Unit Completion Packet

Household Name:        0                                   Funding agreement :       0

Project Address:       0

City:      0                                   , KY               Zip: 0


Was the unit involved in this project constructed
                                                                                         Yes   No
after January 1, 1978?
If yes, stop here and sign the certification below. If no, proceed to the next step.
I certify that this unit was constructed after January 1, 1978.


                                               Signature                                             Date

If NO, was the pre-1978 unit demolished and replaced with
                                                                                         Yes   No
a new unit?
If yes, stop here and sign the certification below. If no, proceed to the next step.
I certify that the pre-1978 unit was demolished and replaced with a new structure.


                                               Signature                                             Date

If NO, did this unit involve rehabilitation other than that which was                    Yes    No
necessary to address lead-based paint hazards?
If yes, complete and attach Section I of the Home Buyer Lead-Based Paint
Rehabilitation Unit Completion Packet and the De Minimis Levels Exemption Form.
Section I of the Lead-Based Paint
Rehabilitation Unit Completion Packet and
De Minimis Levels Exemption form are
attached.
                                              Signature                                              Date
If no, complete and attach Section II of the Home Buyer Lead-Based Paint
Acquisition Unit Completion Packet and the De Minimis Levels Exemption Form.

Section II of the Lead-Based Paint
Acquisition Unit Completion Packet and De
Minimis Levels Exemption form are
attached.
                                               Signature                                             Date
                                           SECTION I
              HOMEBUYER REHABILITATION LEAD-BASED PAINT PROJECT COMPLETION PACKET


                                                                    Household Name: 0

All homebuyer rehabilitation projects involving a structure built before January 1, 1978 are subject to the lead-based paint regulations (24
CFR 35) unless they are demolition-rebuild projects. This packet does not provide complete information on the regulation requirements.
Please check the appropriate boxes if an attachment is included. All questions about this packet should be directed to John Cora at (502) 564-7630,
extension 399.

I. Attach proof (copy of signed statement) that the homebuyer has received disclosure from the previous owners. Ensure that it includes an
acknowledgment that the homebuyer received the pamphlet “Protect Your Family from Lead in Your Home” and that the disclosure occurred prior to
signing the purchase contract.

II. Mark the lead treatment category that was applicable to this project and follow the instructions given.

          A. Up to and Including $5,000
          If all work performed fell under the De Minimis Levels Exemption, questions 1 through 5 below may be skipped. Did all work fall under the
          De Minimis Levels exemption?
                       Yes         No


          If yes, attach a copy of the exemption form you submitted with the project setup.

                    Attach a copy of the paint testing results and a copy of the certification of the individual performing the tests. If you opted to
                    presume the paint was lead based, attach a statement attesting to this.

                    Attach a copy of the notice given to the occupant after paint testing or presumption. The notice should be signed and dated by the
                    occupant on the date they received it. Give the occupant a copy, attach a copy to this packet and keep the original for your records.

                    Attach a copy of the qualification certificate of the workers. Or you may attach a copy of their supervisor’s certification (he/she
                    must be a Kentucky certified lead-based paint abatement supervisor).

                    Attach a copy of the clearance report (clearance of the entire unit is required if containment was not used) and a copy of the
                    certification of the individual performing the clearance. Please remember, if the activities were performed in-house, the individual
                    performing clearance could not have participated in the lead treatment activities. If you hire others to perform the activities, one
                    company must be used to complete treatment and another to complete clearance. The same company can not perform both
                    activities.

                    Attach a copy of the notice given after clearance and/or lead-based paint treatment was achieved. The notice should be signed and
                    dated by the occupant on the date they received it. Give the occupant a copy, attach a copy to this packet and keep the original for
                    your records.

               B. $5,000.01 up to and including $25,000

                    Attach a copy of the paint testing results, the risk assessment and a copy of the certification of the individual performing the
                    tests/risk assessment. If you opted to presume the paint was lead based, attach a statement attesting to this.

                    Attach a copy of the notice given to the occupant after paint testing/risk assessment or presumption. The notice should be signed
                    and dated by the occupant on the date they received it. Give the occupant a copy, attach a copy to this packet and keep the original
                    for your records.

                    Attach a copy of the certification of the supervisor or the qualification certificates of individuals performing the lead-based paint
                    related work.

                    Attach a copy of the clearance report and a copy of the certification of the individual performing the clearance. Please remember,
                    if the activities were performed in-house, the individual performing clearance could not have participated in the lead treatment
                    activities. If you hire others to perform the activities, one company must be used to complete treatment and another to complete
                    clearance. The same company can not perform both activities.

                    Attach a copy of the notice given after clearance was achieved. The notice should be signed and dated by the occupant on the date
                    they received it. Give the occupant a copy, attach a copy to this packet and keep the original for your records.
          C. Greater Than $25,000

                     Attach a copy of the paint testing results, the risk assessment and a copy of the certification of the individual performing the
                     tests/risk assessment. If you opted to presume the paint was lead based, attach a statement attesting to this.

                     Attach a copy of the notice given to the occupant after paint testing/risk assessment or presumption. The notice should be signed
                     and dated by the occupant on the date they received it. Give the occupant a copy, attach a copy to this packet and keep the original
                     for your records.

                     Attach a copy of the certification of all individuals performing the lead-based paint abatement.

                     Attach a copy of the clearance report and a copy of the certification of the individual performing the clearance. Please remember,
                     if the activities were performed in-house, the individual performing clearance could not have participated in the lead treatment
                     activities. If you hire others to perform the activities, one company must be used to complete treatment and another to complete
                     clearance. The same company can not perform both activities.

                     Attach a copy of the notice given after clearance was achieved. The notice should be signed and dated by the occupant on the date
                     they received it. Give the occupant a copy, attach a copy to this packet and keep the original for your records.

III. Occupants of the home must have been relocated unless the rehabilitation was under the De Minimis levels or falls under one of the relocation
exemptions:
                a. Treatment will not disturb lead-based paint or lead-contaminated dust.
                b. Treatment of the interior will be completed within one period in eight daytime hours, the site will be contained, and the work will
                   not create other safety, health, or environmental hazards.
                c. Only the building's exterior is treated; the windows, doors, ventilation intakes, and other openings near the work site are sealed
                   during hazard reduction activities and afterward; and a lead free entry is provided.
                d. Treatment will be completed within five calendar days; the work area is sealed; at the end of each day, the area within 10 feet of the
                   contaminated area is cleared of debris; at the end of each day, occupants have safe access to sleeping areas, bathroom, and kitchen
                   facilities; and treatment does not create other safety, health, or environmental hazards.
                e. Relocation of elderly occupants is not typically required, so long as complete disclosure of the nature of the work is provided and
                   informed consent of the elderly occupant(s) is obtained before commencement of the work.

Work is not considered complete until clearance, if required, is achieved. This makes it extremely unlikely any substantial lead-based paint
treatment project could have been completed without relocating the occupants.

          Were the occupants relocated?
                   Yes          No    N/A - House is Vacant / No Occupants

          If no, which of the above relocation exemptions applied to this project?
             De Minimis Level                        Exemption c


             Exemption a                             Exemption d

                                                                     If you have checked Exemption E, attach elderly consent certification
             Exemption b                             Exemption e     located in the lead-based paint setup packet.


IV.     All lead based paint requirements were fully complied with and documented.


  Printed Name                                                                                                   Date

      Signature

        Agency       0

   Unit address      0

            City     0                                                           KY                  ZIP+4 0
                                SECTION II
     HOMEBUYER ACQUISITION LEAD-BASED PAINT PROJECT COMPLETION PACKET

                                                          Household Name: 0


All homebuyer projects involving a structure built before January 1, 1978 are subject to the lead-based paint
regulations (24 CFR 35) unless they are demolition-rebuild projects. This setup packet does not provide complete
information on the regulation requirements. Boxes to the left of text are for you to check if that attachment is included.
All questions about this packet should be directed to John Cora at (502) 564-7630, extension 399.

      1. Attach proof (copy of signed statement) that the homebuyer has received disclosure from the previous owners.
      Ensure that it includes an acknowledgment that the homebuyer received the pamphlet “Protect Your Family from
      Lead in Your Home” and that the disclosure occurred prior to signing the purchase contract.

      2. Did the visual assessment discover any deteriorated paint? (Visual assessments can only be performed by persons
      successfully completing the training at www.hud.gov/lea/leahome.html)
         Yes                   No

      If no, you may skip to the end of this form, sign it and attach a copy.
      If yes, complete the remainder of the form.

      3. If all work performed fell under the de minimis levels exemption, Questions 4 through 9 may be skipped. Did all
      work fall under the De Minimis Levels Exemption?
         Yes              No



      If yes, attach a copy of the exemption form you submitted with the project setup and proceed to number 10.

      4. Attach a copy of the paint testing results and a copy of the certification of the individual performing the tests. If
      you opted to presume the paint was lead based, attach a statement attesting to this.

      5. Attach a copy of the notice given to the occupant after paint testing or presumption. The notice should be signed
      and dated by the occupant on the date they received it. Give the occupant a copy, attach a copy to this packet and
      keep the original for your records.

      6. Attach a copy of the certification of the supervisor or the qualification certificates of individuals performing the
      lead-based paint related work.

      7. Attach a copy of the clearance report (clearance of the entire unit is required if containment was not used) and a
      copy of the certification of the individual performing the clearance. Please remember, if the activities were
      performed in-house, the individual performing clearance could not have participated in the lead treatment activities.
      If you hire others to perform the activities, one company must be used to complete treatment and another to complete
      clearance. The same company can not perform both activities.

      8. Attach a copy of the notice given after clearance and/or lead-based paint treatment was achieved. The notice
      should be signed and dated by the occupant on the date they received it. Give the occupant a copy, attach a copy to
      this packet and keep the original for your records.

      9. Occupants of the home must have been relocated unless the rehabilitation was under the De Minimis levels or
      falls under one of the relocation exemptions:
             a. Treatment will not disturb lead-based paint or lead-contaminated dust.
             b. Treatment of the interior will be completed within one period in eight daytime hours, the site will be
                contained, and the work will not create other safety, health, or environmental hazards.
             c. Only the building's exterior is treated; the windows, doors, ventilation intakes, and other openings near the
                work site are sealed during hazard reduction activities and afterward; and a lead free entry is provided.
             d. Treatment will be completed within five calendar days; the work area is sealed; at the end of each day, the
                area within 10 feet of the contaminated area is cleared of debris; at the end of each day, occupants have safe
                access to sleeping areas, bathroom, and kitchen facilities; and treatment does not create other safety, health,
             e. Relocation of elderly occupants is not typically required, so long as complete disclosure of the nature of the
                work is provided and informed consent of the elderly occupant(s) is obtained before commencement of the

Work is not considered complete until clearance, if required, is achieved. This makes it extremely unlikely any
substantial lead-based paint treatment project could have been completed without relocating the occupants.

         Were the occupants relocated?
                  Yes           No       N/A - House is Vacant / No Occupants

         If no, which of the above relocation exemptions applied to this project?
             De Minimis Level                   Exemption c


             Exemption a                        Exemption d

                                                                 If you have checked Exemption E, attach elderly consent certification located
             Exemption b                        Exemption e
                                                                 in the lead-based paint setup packet


IV.        All lead based paint requirements were fully complied with and documented.


Printed Name                                                                                                                  Date

      Signature

        Agency    0
Unit address      0
           City   0                                                        KY                         ZIP+4 0
                     DE MINIMIS LEVELS EXEMPTION (Homebuyer)
   Household Name:       0
      Unit Address:      0
               City:     0                                           , KY          Zip: 0
       Subgrantee:       0                                           Funding Agreement:                        0


I am qualified to perform lead-based paint visual assessments (training located at
www.hud.gov/offices/lead/training/visualassessment/h00100.htm). My Visual Assessment Certificate is
attached. I have performed the necessary inspections and determined that the total area of paint to be
disturbed does not exceed the following:
                         20 ft.2 (2m2) on exterior surfaces;
                            2 ft.2 (0.2 m2) in any one interior room or space; or
                          10 percent of the total surface area on an interior or exterior type of component
                         with a small surface area like window sills, baseboards, and trim.

           Printed or typed name:
                          Agency:
                        Signature:
                             Date:

Following to be completed by the person who performed or was responsible for having the repairs
performed:

Prohibited Methods of Paint Removal – The following methods may not be used to remove paint that is,
or may be, lead based paint:
(a) Open flame burning or torching.
(b) Machine sanding or grinding without a high-efficiency particulate air (HEPA) local exhaust control.
(c) Abrasive blasting or sandblasting without HEPA local exhaust control.
(d) Heat guns operating above 1100 degrees Fahrenheit or charring the paint.
(e) Dry sanding or dry scraping, except dry scraping in conjunction with heat guns or within 1.0 ft. (0.30
m.) of electrical outlets, or when treating defective paint spots totaling no more than 2 sq. ft. (0.2 sq. m.) in
any one interior room or space, or totaling no more than 20 sq. ft. (2.0 sq. m.) on exterior surfaces.
(f) Paint stripping in a poorly ventilated space using a volatile stripper that is a hazardous substance in
accordance with regulations of the Consumer Product Safety Commission at 16 CFR 1500.3, and/or a
hazardous chemical in accordance with the Occupational Safety and Health and Health Administration
regulations at 29 CFR 1910.1200 or 1926.59, as applicable to the work.

I understand and have complied with the prohibited methods of paint removal.

        Printed Name:
            Signature:
                 Date:

								
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