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