Program Forms & Flyers

Below is a listing of forms that may be required for participants in Harris County’s recovery programs. While the first six forms must be completed by every applicant, the remaining must only be completed if they apply to the applicant.

If you have any questions about which forms you need to complete, please call or email our Disaster Recovery Hotline at 832-927-8301, DR.Hotline@csd.hctx.net.

Please be advised that information provided in the forms must be true and accurate to the best of your knowledge and belief. Providing false representations on these forms constitutes an act of fraud. False, misleading or incomplete information may result in your ineligibility to participate in Programs that will accept the forms. Warning: Any person who knowingly makes a false claim or statement to HUD may be subject to civil or criminal penalties under 18 U.S.C. 287, 1001 and 31 U.S.C. 3729.

	Form	Purpose	Who Needs It
Forms Required for All Applicants
En Español	Right of Entry	Authorizes Harris County Community Services (HCCSD) and each of their respective employees, vendors, and contractors, the “Right-of-Entry” in and onto the damaged property to perform all necessary activities to carry out the CDBG-DR Program.	All Applicants Interested in Reimbursement and Buyout Program
En Español	Name Affidavit	Establishes that different names found on different documents refer to one person	All (notarized)
En Español	Certification of Homeownership and Agreement to Participate	States applicant is the owner of the damaged home for which assistance is requested, agrees to participate in program, and agrees to provide truthful information, under penalty of perjury.	All applicants
En Español	Insurance Affidavit	States whether applicant has had insurance from the date of the storm to the present, and whether any insurance claims are pending.	All applicants, must be notarized
En Español	Subrogation Agreement	Applicant assigns future payments from FEMA, SBA, insurance and other sources of duplicative benefits to the Program.	All applicants
En Español	Independent Repairs Stop Work Notification	Applicants confirmation that repair work must stop on the project after application to the Program, pending completion of an environmental review for the project	All applicants
Forms Required for Some Applicants
	Form	Purpose	Who Needs It
En Español	Acknowledgement – Lead Based Paint Notification Receipt	Verifies applicant received and read the booklet “Protect Your Family from Lead in Your Home”.	Applicants whose home was built BEFORE January 1, 1978.
En Español	Affidavit of Principal Residency	States damaged home was principal residence at the time of the storm, with supporting evidence.	Applicants who do not have a Homestead Exemption, form must be notarized
En Español	Self Certification of Home Repairs	States repairs done after the storm, value of repairs, and whether or not applicant has receipts. Used during Duplication of Benefits review.	Applicants who have spent money on repairs to their home
En Español	Verification of Disability	Verifies applicant disability (verified by intake specialist observation, receipt of disability benefits or statement from physician).	Applicants who have a disability
En Español	Certification of Zero Income	Verifies that an adult household member who is not employed has no income	Any adult (over 18 years old) member of the household who has had no income for the last 12 months and is not a full-time student.
En Español	Verification of Special Occupancy – Medical Facility	Verifies applicant occupied the property, even if in hospital or nursing facility. Form completed by physician.	Applicant is in a medical/nursing facility now or was in one during the storm.
En Español	Verification of Special Occupancy – Active Duty Military	Verifies applicant occupied the property, even if deployed. Form completed by Authorized Representative of the military service.	Applicant was active duty military assigned away from home at time of storm or is currently assigned away from home
En Español	Verification of Special Occupancy – Incarceration	Verifies applicant occupied the property, even if incarcerated. Form completed by warden.	Applicant was in jail at the time of the storm or is currently in jail.
En Español	Verification of Income from Business	States business income and authorizes program to verify income from business.	Applicant who has income from a business
En Español	Consent to Release Information – Mortgage	Grants permission to a financial institution to release information regarding a mortgage on the damaged property.	Applicants who have a mortgage. Form must be notarized.
En Español	Designee Affidavit	Authorizes a third-party Communications Designee to communicate with the program on behalf of the owner.	Applicants who want to authorize someone else to talk to Harris County Recovery staff on their behalf. Form must be notarized.
En Español	Voluntary Withdrawal Request	Applicant voluntarily withdraws application and states a reason.	All applicants who decide to withdraw from the program, for any reason, including those referred to the Harris County Flood District buyout program.
En Español	Power of Attorney (sample)	Provides guidance for applicants assigning Power of Attorney to another person. (Document is a sample provided as guidance only; no specific form of Power of Attorney is required).	Applicants who want to assign Power of Attorney to another person. (There is no specific form that must be used, this form is provided as a sample.)
En Español	Child Support Affidavit	States the applicant is not more than 30 days delinquent on child support.	Applicants who are court-ordered to pay child support (CSD may use a credit check to check delinquent status instead of this form). Form must be notarized.
En Español	Affidavit of Ownership	States applicant is the owner of the damaged home in the absence of a valid deed of trust, warranty deed, or Statement of Ownership and Location (SOL).	Applicant who cannot provide a valid deed of trust, warranty deed, or Statement of Ownership and Location (SOL).