Completion of This Application Does Not Obligate the Applicant

CITY OF ST. PETERSBURG

WIN HOMEBUYER APPLICATION

Office Phone (727) 893-7247 Fax (727) 893-4100

COMPLETION OF THIS APPLICATION DOES NOT OBLIGATE THE APPLICANT

Applicant(s): Married □ Unmarried □

Street Address:

City: State: Zip:

Phone #’s: Work: Cell: Home:

Number of Adults living in the Household:

Number of Children living in the Household:

Number of People in Household receiving income:

PROPERTY INFORMATION

PROPERTY ADDRESS:

Seller’s Name:

Street Address:

City: State: Zip:

Phone #’s: Work: Cell: Home:

PURCHASE PRICE: $ CONTRACT EXPIRATION DATE:

YEAR BUILT: NUMBER OF BEDRROMS: NUMBER OF BATHROOMS:

Realtor’s Name:

Street Address:

City: State: Zip:

Phone #’s: Work: Cell: Home:______

Lender’s Name: Contact

Street Address:

City: State: Zip:

Phone #’s: Work: Cell: Home:______

ASSETS DISCLOSURE

Do you currently own any real estate? Yes □ No □

Do you have any mortgage loans? Yes □ No □

Checking/ Savings Account: Institution Balance $

Do you have a 401 (K), KEOGH, ROTH, IRA or other retirement account? Yes □ No □

DISPOSAL OF ASSETS

I/WE CERTIFY THAT DURING THE LAST TWO YEARS:

□ I/We have NOT sold, given, or transferred assets of more than $1,000.

□ I/We HAVE sold, given, or transferred assets of more than $1,000.

CHILD SUPPORT/ALIMONY AFFIDAVIT

I/We, acknowledge the following:

1. Check (a), (b), (c) or (d) as applicable:

(a) o I have a court order to receive child support/alimony and do not receive the support

(b) o I am pursing a child support/alimony order.

(d) o I have no court ordered child support or alimony.

2. The absent parent is ordered to pay $ □ weekly □ monthly □ annually

3. The absent parent is approximately $ in arrears. The last payment of child support/alimony I received was on (date).

4. I/We are court ordered to PAY child support and or alimony. Yes □ No □

If yes, the amount of support is $ □ weekly □ monthly □ annually

5. I/We have □ or have not □ previously received financial ASSISTANCE from the City of St.

Petersburg Working to Improve our Neighborhood (W.I.N.) Program or through any other agency i.e. St. Petersburg Housing Authority or St. Petersburg Neighborhood Housing Services.

If yes: (Date).

HOMEBUYER EDUCATION INFORMATION

We/I □ HAVE or □ HAVE NOT completed the HOMEBUYER EDUCATION WORKSHOP

AGENCY CONDUCTING CLASS:

DATE OF CERTIFICATION:

The Homebuyer Education Workshop is a mandatory requirement of this program. Classesare administered in Pinellas Countyby Community Service Foundation (461-0618), Tampa Bay Community Development Corporation (442-7075) & St. Petersburg Neighborhood Housing Services (821-6897). A certificate of completion is required prior to loan closing. Enroll as soon as possible so that you can attend the next available class and not worry about delaying your closing! This is a free workshop.

I/We acknowledge this information to be true and correct. I/We fully understand that it is a Federal crime, punishable by fine and or imprisonment, to knowingly make any false statements when applying for this mortgage, as applicable under the provision of title 18, United States Code, Section 1014. I/We further understand that random audits are conducted by the City of St. Petersburg and other governmental agencies. Should omissions or misrepresentations (most notably about income and/or household size) be uncovered, I/We may be subject to immediate payment of all assistance received or possible foreclosure of my property. I/We authorize the City of St. Petersburg W.I.N. Program to verify any or all of the information provided on this form.

Borrower's Signature Date

INCOME INFORMATION for ALL HOUSEHOLD OCCUPANTS

Applicant:

Name:

Social Security #: Date of Birth:

Employer: Phone Gross Monthly Income: $

Alimony: $ Child Support: $ □ Weekly □ Bi-weekly □ Monthly

AFDC: $ Pension: $ Disability: $

Social Security: $ Other: $ (Specify Type: )

Signature:

Co-Applicant and Other Household Members:

Name: Relationship:

Social Security #: Date of Birth:

Employer: Phone Gross Monthly Income: $

Alimony: $ Child Support: $ □ Weekly □ Bi-weekly □ Monthly

AFDC: $ Pension: $ Disability: $

Social Security: $ Other: $ (Specify Type: )

Signature:

Name: Relationship:

Social Security #: Date of Birth:

Employer: Phone Gross Monthly Income: $

Alimony: $ Child Support: $ □ Weekly □ Bi-weekly □ Monthly

AFDC: $ Pension: $ Disability: $

Social Security: $ Other: $ (Specify Type: )

Signature:

Name: Relationship:

Social Security #: Date of Birth:

Employer: Phone Gross Monthly Income: $

Alimony: $ Child Support: $ □ Weekly □ Bi-weekly □ Monthly

AFDC: $ Pension: $ Disability: $

Social Security: $ Other: $ (Specify Type: )

Signature:

Name: Relationship:

Social Security #: Date of Birth:

Employer: Phone Gross Monthly Income: $

Alimony: $ Child Support: $ □ Weekly □ Bi-weekly □ Monthly

AFDC: $ Pension: $ Disability: $

Social Security: $ Other: $ (Specify Type: )

Signature:

Name: Relationship:

Social Security #: Date of Birth:

Employer: Phone __ Gross Monthly Income: $

Alimony: $ Child Support: $ □ Weekly □ Bi-weekly □ Monthly

AFDC: $ Pension: $ Disability: $

Social Security: $ Other: $ (Specify Type: )

Signature:

SOCIAL SECURITY NUMBER COLLECTION POLICY DISCLOSURE

The City of St. Petersburg Working to Improve our Neighborhoods (W.I.N) Program collects social security numbers from prospective mortgage loan and grant recipients during the application process to determine credit worthiness of the applicant, data collection, benefit processing and tax reporting.

CONSENT LETTER

We/I hereby consent that the City of St. Petersburg (City), or any credit reporting agency or bureau designated by the City, may collect and retain any and all information concerning our/my employment, bank accounts, credit card accounts, installment obligations and any other matter, which may be required in processing our/my application for a mortgage loan. We/I also authorize release of related information by our/my employer(s), designated credit reporting agency or bureau, financial institution(s), government agencies and any other creditors as listed in my/our application for a mortgage loan.

This “consent letter” may be photocopied and all copies shall be as effective as that which contains original signatures dated this ______day of , 2009 .

Applicant: Co-Applicant:

Print Name Print Name

______

Signature Date Signature Date

______

Street Address Zip Code Street Address Zip Code

______

Social Security Number Social Security Number

SOCIAL SECURITY NUMBER COLLECTION POLICY DISCLOSURE

CONSENT LETTER

This “consent letter” may be photocopied and all copies shall be as effective as that which contains original signatures dated this ______day of , 2009 .

OTHER HOUSEHOLD OCCUPANTS

As listed on W.I.N. Application

1) 2)

Print Name Print Name

Signature Date Signature Date

Street Address Zip Street Address Zip

______

Social Security Number Social Security Number

3) 4)

Print Name Print Name

Signature Date Signature Date

Street Address Zip Street Address Zip

______

Social Security Number Social Security Number

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