Rev. 1/26/02 10:22 PM
JASPER COUNTYHABITAT FOR HUMANITY
Application for Housing
NAMESOC. SEC. # DATE OF BIRTH
NAMESOC. SEC. # DATE OF BIRTH
STREET ADDRESS ______PHONE NUMBER *
CITY, STATE, ZIP
LENGTH OF TIME AT THIS ADDRESS RENT OR OWN?
NAME/RELATIONSHIP SOC. SEC. # DOB
All others living at
this address (include
relationship to you)
PLEASE PROVIDE A CURRENT FEDERAL INCOME TAX RETURN
ALONG WITH THE FOLLOWING INFORMATION
HOUSING HISTORY (PREVIOUS TEN YEARS):
ADDRESSLANDLORD AND PHONE #
1.
DATES LIVED THERE
2.
DATES LIVED THERE
3
DATES LIVED THERE
4.
DATES LIVED THERE
CURRENT EMPLOYMENT:
ADULT 1 ADULT 2
EMPLOYER
POSITION
PHONE NUMBER
SUPERVISOR
TIME ON JOB
Other Household Income:
EMPLOYMENT HISTORY:
EMPLOYER SUPERVISOR AND PHONE # DATES HELD
ADULT 1
ADULT 2
REFERENCES: (LIST THREE PEOPLE WHO KNOW YOU WELL - NOT A RELATIVE. FOR
EXAMPLE, YOUR PASTOR, FRIENDS OR NEIGHBORS).
1. NAME, ADDRESS, PHONE
HOW DO YOU KNOW THEM?
2. NAME, ADDRESS, PHONE
HOW DO YOU KNOW THEM?
3. NAME, ADDRESS, PHONE
HOW DO YOU KNOW THEM?
LIST TOTAL MONTHLY INCOME:
ADULT 1 ADULT 2
GROSS PAY
TAKE HOME PAY
WIC
AFDC
FOOD STAMPS
SOCIAL SECURITY
DISABILITY
PENSION
ALIMONY
CHILD SUPPORT
SSI
OTHER
LIST ALL DEBT*: TO WHOM, PURPOSE, PHONE #, BALANCE AND MONTHLY PAYMENT.
(Example):Bank of America car loan 866-5555 $1575.00 $350.00
MONTHLY HOUSEHOLD LIVING EXPENSES:
HOUSINGHEALTHEDUCATION
Rent or mortgage payment Medical School supplies______
Real estate taxes (separate) Dental Book fees______
Real estate insurance " _Prescriptions Tuition______
Gas TOTAL______TOTAL ______
Electric
Water/sewage/trash TRANSPORTATIONSAVINGS
Phone Car payments Monthly______
Furniture/appliances Auto insurance ______TOTAL ______
TOTAL Maintenance
Gasoline and oil DEPENDENT CARE
FOODPublic Tran. Childcare______
Groceries (w/paper goods) TOTAL Child support______
Lunch out Other______
Dinner out INSURANCE TOTAL ______
TOTAL Life
Health DEBTS
CLOTHINGTOTAL Loans______
New purchases Credit cards______
Cleaning expenses ENTERTAINMENT TOTAL______
TOTAL Vacation/travel
Allowances______CONTRIBUTIONS
PERSONAL CARECable Church______
Hair cuts Video rental Charities______
Toiletries Newspaper Other______
TOTAL______Literature TOTAL______
TOTAL______
COMBINED TOTAL EXPENSES:
HOUSINGENTERTAINMENT
FOODEDUCATION
CLOTHINGSAVINGS
PERSONAL CAREDEPENDENT CARE
HEALTHDEBTS
TRANSPORTATIONCONTRIBUTIONS
INSURANCEGRAND TOTAL
HAVE YOU EVER FILED FOR BANKRUPTCY?WHAT YEAR?
DO YOU HAVE ANY OUTSTANDING TAX WARRANTS OR JUDGEMENTS?
ARE YOUR WAGES BEING GARNISHED?
HAVE YOU EVER APPLIED FOR A MORTGAGE? APPROVAL/DENIAL?
DO YOU HAVE ANY OUTSTANDING MEDICAL BILLS?
- By signing this application, you are giving the Family Selection Committee permission to verify any and all information given.
- If any statement is found to be false, your application will automatically be disqualified.
By signing below, I/we attest that all disclosed information is true
and complete to the best of my/our knowledge.
SignatureDate
SignatureDate
1