Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.
The following form may request personally identifiable or protected health information. Please see our Privacy Policy for details. This form is encrypted. SSL is on to ensure a higher level of security. A recaptcha must be completed before submission, you cannot save progress, and you cannot receive an email copy of the form.

Rehabilitation/Reconstruction Application

  1. City of Bristol, Tennessee
    Emergency Rehabilitation Application

    Community Development Block Grant Program

  2. Community Development Department
    Planning Division
    Municipal Annex Building
    104 8th Street
    P.O. Box 1189
    Bristol, TN 37620
    Phone:423-989-5521
    Fax: 423-989-5717
  3. A. PERSONAL INFORMATION
  4. Marital Status
  5. Children
    List only if living with you.
  6. Does anyone in the household receive disability benefits?
  7. Summary of Household
  8. B. DWELLING STRUCTURE
  9. 1. Type of Structure
  10. 6. Water/Wastewater
  11. 7. Do yo have home owner's insurance?
  12. 8. Do you make a house payment?
  13. 9. Do you own any other properties?
  14. C. FAMILY INCOME CALCULATION
  15. 5. ASSETS
  16. (bank accounts, stocks/bonds, life insur, retire svgs)
  17. (bank accounts, stocks/bonds, life insur, retire svgs)
  18. (bank accounts, stocks/bonds, life insur, retire svgs)
  19. (bank accounts, stocks/bonds, life insur, retire svgs)
  20. Total of all current market value line items.
  21. Total of all income from assets line items.
  22. 6. SUMMARY OF INCOME DATA (Anticipated income over the next year)
  23. Add all totals for each family member together
  24. Assets Income - Enter greater of lines 5b or 5c above
  25. Total Anticipated Income - 6a
  26. Annual Income - Assets Income plus Total Anticipated Income
  27. E. VERIFICATION
  28. Using
  29. 1. Prove ownership of your home by providing a copy of the deed.
    2. Provide proof of homeowner insurance.
    3. Provide proof that property taxes are paid up to date.
    4. Allow inspection by the Grantee of the property whenever the Grantee determines that such inspection is necessary.
    5. Upon completion of the rehab, agree to maintain the property in a clean, neat and sanitary condition.
    6. Have alternative housing during the time period of the rehabilitation project when the removal of lead-based paint hazards is necessary.
    7. Permit the contractor to use, at no cost, reasonable existing utilities such as gas, water and electricity which are necessary to the performance and completion of the work.
    8. Cooperate fully with the Grantee and the contractor to ensure that the rehabilitation work will be carried out promptly.
    9. Possess the ability to maintain the condition of a rehabilitated home.
  30. G. CERTIFICATION
  31. To the best of my knowledge, I certify that the information in this application for federal assistance through the CDBG program is true and correct. I will comply with the CDBG program rules and regulations if assistance is approved. I also certify that I am aware that providing false information on the application can subject the individual signing such application to criminal sanction up to and including a Class B Felony.
  32. Leave This Blank: