Texas General Land Office
                                                                                      Community Development and Revitalization
                                                                                           CDBG-DR Buyout / Acquisition Program
                                                                                                           Applicant Activity File
                                                                                                  Voluntary Buyout/Acquisition
                                                                                           Left Side Documentation Checklist 
                     Homeowner Name:
                      Activity Number:                             Incentive Activity Number (If Applicable):
                        Street Name:                                                    Subrecipient Name:
                            City:                                  Zip Code:
                          County:
                         Program Type  (Check one):                      Voluntary Buyout                Voluntary Acquisition
                         What activities and incentives are included?                     Low to Moderate Housing (LMH)
                         Select all that apply.                                            Low to Moderate Buyout (LMB)
                                                                                     Low to Moderate Housing Incentive (LMHI)
                                                                                                 Urgent Need (UN)
                                                                                                 Slum & Blight (SB)
                                                            LEFT SIDE DOCUMENTATION 
                  All documentation should be filed thoroughly in the order identified below to ensure case clarity and file consistency.
                                                              GLO Form Name           Included in 
                        Documentation Sections                      and/or                file:                Comments
                                                                 Information          Yes, No, NA
                  Summary Document
                         Applicant Activity File          This Document completed 
                         Left Side Documentation           and the file supported as 
                         Checklist                          the application process 
                                                                 progresses.  
                  Applicant Information:
                         Intake Beneficiary                      GLO Form:
                         Application                          Intake Beneficiary 
                         Include all supporting                   Application
                     1   documents identified on page 6 
                         of the Intake Beneficiary 
                         Application in addition to those 
                         identified below to support each 
                         applicant's request.              Homeowner Certification 
                                                              and Agreement to 
                                                                  Participate
                                                                 HUD Form:
                                                             General Information 
                                                           Notice Residential Tenant 
                                                           to be Displaced (Tenant 
                                                                     Only)
                         Documentation of applicability      Provide evidence of 
                     2   of URA (Tenant or Involuntary      delivery by certified or 
                         buyouts or acquisitions only)       registered first class
                                                              mail, return receipt 
                                                                requested, or a 
                                                             certification of hand 
                                                                   delivery
                         Affidavit of Same Name 
                     3   Provides documentation for              GLO Form:
                         applicants who may be known       Affidavit of Same Name
                         by more than one name.
                                                                               1
                          Disaster Damage                    Provide all documentation 
                          Verification                       confirming direct damage: 
                          Documentation verifying that          damage or insurance 
                      4   the specific applicant's             estimates, FEMA data, 
                          identified property received             SBA data, other 
                          direct damage from the              documentation noted in 
                          disaster.                               Program Housing 
                                                                     Guidelines 
                          Child Support Status               Provide documentation on 
                          Verification                           the status of court-
                          All applicants and co-applicants  ordered Child Support as 
                          must be current on payments        verified through the Texas 
                      5   for child support. If the          Office of Attorney General 
                          applicant or co-applicant is not    (OAG), and/or proof of an 
                          current on child support, that     established Payment Plan. 
                          member will be required to                        
                          enter into a payment plan.
                                                                     GLO Form:
                                                               Adjusted Gross Income 
                                                               (AGI) and Area Median 
                                                             Income (AMI) Verification 
                          National Objective                        GLO Form: 
                          Documentation                             Urgent Need
                      6   Federal funding carries a              National Objective
                          requirement to meet one of           Self-Certification Form
                          several identified National 
                          Objectives.
                                                                    GLO Form: 
                                                                  Slum and Blight
                                                                 National Objective 
                                                               Self-Certification Form
                                                             Provide mobility-impaired 
                                                               ID card OR letter from 
                          Verification of                    doctor stating homeowner 
                      7   Disability/Special Needs             or household member 
                                                                qualifies as disabled, 
                                                              Social Security Disability 
                                                                       Notice
                                                                     GLO Form:
                                                               DOB Calculation Form
                                                                     GLO Form:
                                                                 DOB Eligible Repairs 
                                                                  Calculation Form
                          Duplication of Benefit (DOB)
                          Reconciliation Documents to                GLO Form:
                      8   include copies of homeowner(s)  DOB Insurance Affidavit
                          checks to verify any reduction 
                          of scope.                           Provide DOB Supporting 
                                                                  Documentation - 
                                                             FEMA assistance (if any), 
                                                              SBA assistance (if any), 
                                                               Insurance proceeds (if 
                                                                        any), 
                                                                   USACE (if any), 
                                                                 NCRS (if any), etc.
                          Subrogation Agreement
                          The agreement defining the 
                          substitution of homeowner(s) 
                          by the GLO in respect of a debt            GLO Form:
                      9   or insurance claim,                 Subrogation Agreement
                          accompanied by the transfer of 
                          any associated rights and 
                          duties regarding the specific 
                          property defined.
                   Property Information:
                                                                                   2
                          Map clearly indicating the         Provide PDF FEMA map 
                     10 location of the property overlaid     with property clearly 
                          with DRRA or floodplain                   indicated.
                          delineated. 
                                                            Provide 2019 tax records 
                          Documentation of Principle             with homestead 
                     11 Residency and Supporting             exemption, utility bill at 
                          Documents (If applicable)        the time of disaster, or tax 
                                                             assessors indication of 
                                                             homestead exemption. 
                          Mortgage Company/Lender 
                     12 Information and Supporting        Provide Mortgage Statement 
                          Documentation (If Applicable)
                     13 National Flood Insurance             Provide Flood Insurance 
                          Verification (NFIP) (if any)           Documentation 
                          Documentation of Ownership, 
                     14 Statement of Ownership              Provide Deed in Applicant 
                          Location (For Mobile Homes          Name or Title Abstract
                          only)
                          Well Abandonment 
                          Certification                            GLO Form:
                     15 Applicant's certification              Well Abandonment 
                          regarding well abandonment               Certification
                          records.
                          Hazardous Material 
                          Disclosure Certification                 GLO Form:
                     16 Applicant's certification              Hazardous Material 
                          regarding the presence or          Disclosure Certification
                          absence of contamination from 
                          toxic or hazardous substances.
                           Work Write-up/Cost Estimate
                          Final Revised and Original. 
                          Include before and after photos. Pictures and scope of work 
                     17 Unmet need documentation-                  to demolish 
                          damage assessment , including 
                          inspection checklist or initial 
                          inspection checklist short. 
                   Supplemental Documentation:
                          SAMPLE:  Homeowner 
                          Application Denial Letter
                          SAMPLE:  Homeowner Appeal 
                          Form
                          SAMPLE:  Homeowner Letter of 
                          Withdrawal                       Subrecipients may use the 
                          SAMPLE: HUD Handbook 1378  sample provided or their 
                     18 Appendix 31 Voluntary                   own as long as all 
                          Acquisition Information Notice    program requirements are 
                          ( Agencies without Eminent                   met.
                          Domain Authority)
                          SAMPLE:  HUD Handbook 1378 
                          Appendix 32 Voluntary 
                          Acquisition Information Notice 
                          ( Agencies with Eminent 
                          Domain Authority)
                                                             Informational document 
                                                             on how to demonstrate 
                          INSTRUCTION: How to Indicate          the location of the 
                     19 the Property's Location in Flood      property in relation to 
                          Zone                              FEMA established Special 
                                                             Hazard Flood Areas and 
                                                                    Floodways
                   Disclaimer: The Texas General Land Office has made every effort to ensure the information contained on this form is accurate and in 
                   compliance with the most up-to-date CDBG-DR and/or CDBG-MIT federal rules and regulations, as applicable. It should be noted that the Texas 
                   General Land Office assumes no liability or responsibility for any error or omission on this form that may result from the interim period 
                   between the publication of amended and/or revised federal rules and regulations and the Texas General Land Office's standard review and 
                   update schedule.
                   Effective10/18/2020
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