820 14th Street West WELL-SEPTIC CONVERSION App 05.11.2011 i
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City of Atlantic Beach • 800 Seminole Road •Atlantic Beach,Florida 32233-5445
Phone: (904)247-5800 • Fax (904)247-5805 • http://www.coab.us
APPLICATION FOR ASSISTANCE
WITH CONVERSION FROM
WELL AND SEPTIC TANK TO CITY WATER AND SEWER
FY 2011-20-12 COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAM
The information requested on this form is required in order to determine your eligibility to participate in this
program. (These funds may be available to homeowners whose incomes are within low and moderate levels
based upon family size and as established by HUD Section 8 Income Limits.) Please answer all questions,
and provide copies of all required documents. (Your information is considered confidential.) Funds for this
program are available only to owner-occupied homes. In the case of a duplex or two-family dwelling, the
property owner must live full-time in one of the two units as documented by a valid homestead exemption.)
Grant funds are limited, and applicants are selected based upon most urgent and serious need and
availability of funds.
DATE: /// hot I
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1. Homeowner Name(s): �UZ- /T
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2. Address of Home: 2-6 114 1,0 -k
3. Telephone Number: 6,2- S(') c1 (day) (night)
4. Is the person completing this application the Head of Household? ❑ yes ❑ no ❑ female ❑ male
5. How many family members live in this house? I
6. Are there people living in this house with disabilities or special needs? ❑ yes 0 no If yes, please
explain
7. Number and age of persons living in the household in addition to Head of Household.
Ages 0-5 years old Male Female
Ages 6- 17 years old Male Female
Ages 18-39 years old Male Female
Ages 40-64 years old Male I Female
Ages 65 and older Male Female
8. Water supply is provided by: ['City Water [Private Well Other
9. Does septic system work properly? Yes ❑ No If no, please explain.
Page 1 of 3
10. Does your plumbing work properly? C9 Yes ❑ No
If no, please explain.
11. Is there hot and cold running water in your house? Q Yes ❑ No
12. Do you have a complete kitchen with running water,a refrigerator and cooking facilities? tl
13. How many persons are in your family and living at this address?
14. Federal regulations require that we keep track of certain demographic information and the type of
households being served. Please check the appropriate box below.
White,Not Hispanic
❑ African-American,Not Hispanic
❑ American Indian or Native Alaskan
❑ Hispanic
❑ Asian or Pacific Islander
❑ Female Head of Household
❑ Other
15. What is the total annual income(before taxes)of your household? Li 3,(0-?
16. Are you on a fixed income such as Social Security, SSI or retirement? ❑ Yes [No
17. What are your sources of income? `j 1 ?1/14/)14
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18. Do you own this home? 111.4s ElNo
If you own your home, please provide a copy of your deed and a recent water or electric bill which shows that
you live at this address. If you rent your home, please provide a copy of the lease.
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Signature of Owner Date
If you have any questions about this application or need any assistance preparing
the application, please contact the City of Atlantic Beach at (904) 247-5817.
The following Income Verification Form must also be completed and mailed or
delivered to:
Community Development Department
City of Atlantic Beach
800 Seminole Road
Atlantic Beach, Florida 32233
Please provide the time of day and day of the week (Monday through Friday) when it would be
most convenient to make arrangements for a City Inspector to meet with you, and the phone
number where you wish to be called. (es 'S 57
/1147 y , 71944id y 07
Page 2 of 3
INCOME VERIFICATION FORM
PART I. (To be filled out by the person (employee) completing this application.)
Applicant/ Employee name: i
Address: `b )1414' 5 Li
Social Security Number: 257-- 1 i (
I hereby authorize release of my income information to the City of Atlantic Beach for
the purpose of applying for participation in the septic to sewer conversion funding
assistance Program, which is funded by a Community Development Block Grant.
1 -
Signature of Owner Date
PART II. (To be filled out by employer, Social Security Administration or HRS.)
Please provide the following information and return to:
Community Development Department
City of Atlantic Beach
800 Seminole Road
Atlantic Beach, Florida 32233
Applicant/ Employees Name: � _bf Pt S inm416
Gross Monthly Income: $ 336u
Is employment: Rp rmanent n part-time temporary
Employer Name: &zc‘s:i L 41X ci
Address: lc l # L 1 Telephone: &210
Name and title of person providing this information. Date
Page 3 of 3
Property Appraiser - Property Details Page 1 of 2
SIMMONS DEBRA A Primary Site Address Official Record Book/Page Tile#
820 W 14TH ST 820 W 14TH ST 13034-00390 9418
ATLANTIC BEACH, FL 32233-1805 Atlantic Beach FL 32233
820 W 14TH ST
Property Detail Value Summary
RE# 171047-0000 2010 Certified i 2011 In Progress
Tax District USD3 Value Method CAMA CAMA
Property Use 0100 SINGLE FAMILY Total Building Value $122,050.00 $97,228.00
#of Buildings 1 ^ Extra Feature Value $18,545.00 _ $18,092.00
18-34 38-2S-29E.281 Land Value(Market) $80,100.00 $80,100.00
Legal Desc. ATLANTIC BEACH SEC H Land Value(Agric.) $0.00 $0.00
Subdivision 03119 ATLANTIC BEACH SEC H Just(Market)Value $220,695.00 $195,420.00
The sale of this property may result in higher property taxes.For more information go Assessed Value $165,371.00 $167,851.00
to Save Our Homes and our Property Tax Estimator.Property values,exemptions and Cap Diff/Portability Amt $55,324.00/$0.00 $27,569.00/$0.00
other information listed as'In Progress'are subject to change.These numbers are
part of the 2011 working tax roll and will not be certified until October.Learn how the Exemptions $50,000.00 See below
Property Appraiser's Office values property. Taxable Value $115,371.00 See below
Taxable Values and Exemptions—In Progress
If there are no exemptions applicable to a taxing authority,the Taxable Value is the same as the Assessed Value listed above in the Value Summary box.
County/Municipal Taxable Value SJRWMD/FIND Taxable Value School Taxable Value
Assessed Value $167,851.00 Assessed Value $167,851.00 Assessed Value $167,851.00
Homestead Exemption(HX) -$25,000.00 Homestead Exemption(HX) -$25,000.00 Homestead Exemption(HX) -$25,000.00
Amend 1 Homestead(HB) -$25,000.00 Amend 1 Homestead(HB) -$25,000.00 Taxable Value $142,851.00
Taxable Value $117,851.00 Taxable Value $117,851.00
Sales History
Book/Page Sale Date I Sale Price I peed Instrument Type Code Oualified/Unqualified Vacant/Improved
13034-00390 1/18/2006 $25,000.00 I QC-Quit Claim Unqualified Improved
09972-01786 4/27/2001 $139,000.00 WD Warranty Deed Qualified Improved
( 09263-00672 4/5/1999 $40,000.00 WD-Warranty Deed Unqualified Improved
07868-01874 5/31/1994 $87,000.00 WD-Warranty Deed Qualified Improved
07283-00122 2/24/1992 $100.00 WD-Warranty Deed Unqualified Improved
Land&Legal
Land Lesal
LN Code I Use Description Zoninq I Front Depth I Category I Land Units Land Value I LN Legal Description
1 0100 I RES LD 3-7 UNITS PER AC ARS-2 ( 120.00 102.00 I Common 1120.00 $80,100.00 1 118-34 38-2S-29E.281
2 ATLANTIC BEACH SEC H I
13 LOTS 1,2 BLK 222 I
Buildings
Building 1
Building 1 Site Address Element Code Detail
820 W 14TH ST
Atlantic Beach FL 32233 Exterior Wall 6 6 Vert Sheet Siding 1725..7Roofing Structure 3 3 Gable or Hip L_a
Building Type 0101-SFR 1 STORY SOH Roofing Cover 3 3 Asph/Comp Shingle 7
Year Built 1971 Interior Wall 5 5 Drywall BASI
Int Flooring 11 11Ceramic Clay Tile
Tvce Gross Area Heated Area Int Flooring 12 12 Hardwood .,
, . , 3_1
Fin Screened Porch 264 0 Heating Fuel 4 4 Electric
Base Area 2278 2278 Heating Type 4 4 Forced-Ducted — I
Finished Open Porch 32 0 Air Conditioning 4 4 Packaged Unit
Total 2574 2278
Element Code
Stories 1.000
Bedrooms 3.000
http://apps.coj.net/pao property Search/Basic/Detail.aspx?RE=171 ... 9/9/2011
Property Appraiser - Property Details Page 2 of 2
I Baths 2.000
Rooms/Units 1.000
http://apps.coj.net/pao propertySearchBasic/Detail.aspx?RE=171... 9/9/2011
J� CITY OF ATLANTIC BEACH
sty 800 SEMINOLE ROAD
.1510
�.ss._ s ATLANTIC BEACH, FLORIDA 32233-5445
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J 1 TELEPHONE: (904) 247-5800
FAX: (904) 247-5805
1.'401119� www.coab.us
June 27,2011
Debra A. Simmons
820 14t Street West
Atlantic Beach, FL 32233
Dear Ms. Simmons;
The purpose of this letter is to confirm that the City of Atlantic Beach has received your APPLICATION
FOR ASSISTANCE WITH CONVERSION FROM WELL AND SEPTIC TANK TO CITY WATER
AND SEWER.
At the present time,the City is compiling the applications and information so that we can schedule these
projects in the coming year. The funding should be available starting in October 2011.
City staff will contact you to review your application to assure that you qualify for the financial
assistance. Additionally, staff will provide you with direction and guidance so that you can obtain
qualified help to perform the services. This will be explained to you in more detail within the next few
months.
In the meantime, if you any have questions,then you are welcome to contact me for further discussion.
Thank you for expressing your interest in this program.
Sincerely yours,
.,..72
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David E. Thompson
Asst. City Manager