The Whittier Townhome Community Name * First Name Last Name Social Security Number or ITIN Number * Birth Date MM DD YYYY Home Phone (###) ### #### Cell Phone (###) ### #### Work Phone (###) ### #### Preferred Phone Home Cell Work Company Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date moved to this address APPLICANT EMPLOYMENT Information provided in this section is for the last 2 years Primary Employer Company Company Phone (###) ### #### Title Hire Date Company Address Address 1 Address 2 City State/Province Zip/Postal Code Country Applicant works Part-Time Full-Time Hours per week 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 + Gross Income $ Hourly Rate Amount Paid Hourly Weekly Frequency Every 2 weeks Twice a month Monthly How did you hear about Green Country Habitat for Humanity? What is your primary housing concern? (select all that apply) Affordability Space Safety House has a problem, not functional Other What would affordable homeownership mean to you and your family? Have you tried to purchase a home before? Yes No If yes, what were some of the barriers? Current Housing Arrangement Monthly Rent Homeowner with mortgage Homeowner with mortgage paid off Living with a family member or friend Homeless Household Type Single Mother Single Father Single without children Two or more unrelated adults Married with children Married without children Other Household Size 1 2 3 4 5 6 7 8 9 10 11+ Annual Gross Household Income $ Dependent Name - Birth Date - Relationship to Applicant MONTHLY HOUSEHOLD INCOME Income Source - Applicant (Monthly) Salary $ Alimony or Child Support $ Social Security $ Pension Income $ Public Assistance $ Self-Employment Income $ Dependent SSI Income $ Race Select one White Black or African American American Indian/Alaskan Native Asian Native Hawaiian/Other Pacific Islander American Indian/Alaskan Native & White Asian & White Black/African American & White American Indian/Alaskan Native & Black Other Ethnicity Hispanic Non Hispanic Immigrant Status Yes No Marital Status Single Married/Domestic Partner Divorced Separated Gender Male Female Transgender Other SPECIAL NEEDS AND PROGRAM QUESTIONS Are you willing to attend financial education and/or credit counseling that provide education on how to avoid recurring debts that cannot be repaid through establishing an effective debt management plan or budget? Yes No Are you willing to complete "sweat equity" hours volunteering for Green Country Habitat, either on your own home or at another site (construction, ReStore, offices, etc.) Yes No Are you, or a member of your household, currently recovering from physical, alcohol or drug abuse? Yes No Are you, or a member of your household, being treated for HIV or AIDS? Yes No Have you, or any member of your household, served in the military, including National Guard and Reserves? Yes No Are you, or any member of your household, disabled or handicapped (please include physical and mental disabilities? Yes No **This information is private and protected by law and is only used for special programming requirements** AUTHORIZATION I authorize the housing Counseling Agency to: a) Pull my/our credit report to review my/our credit file for housing counseling in connection with my pursuit on a loan to purchase real property; b) Pull my/our credit report and review my/our credit file for informational inquiry purposes: and c) Obtain a copy of the HUD-1 Settlement Statement, Appraisal, and Real Estate Note(s) when I purchase a home, from a lender who made me/us loan and/or the title company that closed the loan. I/We understand that any intentional or negligent representation(s) of the information contained on this form may result in the civil liability and/or criminal liability under the provisions of Title 18, United States Code, Section 1001. I understand Date MM DD YYYY Thank you!
