Applicant Intake Form Date of Intake:
APPLICANT Please Print Clearly
Name:
First MI Last
Street
City State Zip Code
Home: (_____) ______–______Work: (______) ______–______Email: ______
Mobile/Cell (_____) ______–______
______–______–______/______/______
Social Security Number Birth Date
Ø Race (please select one):
White Black or African American American Indian/Alaskan Native
Asian Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native and White Asian and White Black/African American and White
American Indian/Alaskan Native and Black Other
Ø Ethnicity (please select “yes” or “no” for Hispanic Origin) Hispanic: Yes No
You should select both a “Race” category and a “yes” or “no” for Hispanic origin
Ø Marital Status: Single Married Divorced Separated Widowed
Ø Gender: Male Female
Ø Disabled/ Handicapped? Yes No
Ø Current Housing Arrangement (please select one):
Renting Homeless
Homeowner with mortgage Living with family member and not paying rent
Homeowner with mortgage paid off Other (please specify):
Ø Do you currently live in a Housing Authority of Texarkana Texas property? Yes N
If yes, where?
Ø Are you a HOPE VI resident (lived in Covington Homes, Stevens Courts or Griff King after September 2008)?
Yes No If yes, where?
Ø Household Type (please select the most accurate)?
Female headed single parent household Male headed single parent household Two or more unrelated adults
Married with children Married without children Single adult Other
Ø Family/Household Size: How many dependents (other than those listed by any co-borrower)?
What ages are they? , , , , , , , , , , , ,
Are there non-dependents who will be living in the home? Yes No If yes, list below:
Relationship Age Relationship Age
Relationship Age Relationship Age
Ø Total gross Annual Family / Household Income: $______
Ø Education (please select one):
Below High School Diploma High School Diploma or Equivalent
Two-Year College Bachelors Degree
Masters Degree Above Masters Degree
Ø Referred to by (please select all that apply):
Print Advertisement Bank Government TV Realtor
Staff/Board member Walk-In Friend Radio Newspaper Article
If you were referred by a bank, which one?
If referred by another source not listed above, which one?
APPLICANT EMPLOYMENT — List ALL Employers for the Last 2 Years Please Print Clearly
Current Employer:
Street City State Zip Code
Title Supervisor
(______) ______–______Part-Time Full-Time
Phone Start Date
Starting Wage: $ hourly weekly every two weeks twice a month monthly
Current Wage: $ hourly weekly every two weeks twice a month monthly
APPLICANT EMPLOYMENT — List ALL Employers for the Last 2 Years Please Print Clearly
Current Secondary Employer:
Street City State Zip Code
Title Supervisor
(______) ______–______Part-Time Full-Time
Phone Start Date
Starting Wage: $ hourly weekly every two weeks twice a month monthly
Current Wage: $ hourly weekly every two weeks twice a month monthly
Previous Employer:
Street City State Zip Code
(______) ______–______
Title Phone
Part-Time Full-Time
Start Date End Date
Starting Wage: $ hourly weekly every two weeks twice a month monthly
Ending Wage: $ hourly weekly every two weeks twice a month monthly
Why did you leave?
Previous Employer:
Street City State Zip Code
(______) ______–______
Title Phone
Part-Time Full-Time
Start Date End Date
Starting Wage: $ hourly weekly every two weeks twice a month monthly
Ending Wage: $ hourly weekly every two weeks twice a month monthly
Why did you leave?
(Continue listing previous employers on a separate sheet of paper)
CO-APPLICANT
Name:
First MI Last
Street
City State Zip Code
Home: (_____) ______–______Work: (______) ______–______Email: ______
Fax: (_____) ______–______Pager: (_____) ______–______Mobile/Cell (_____) ______–______
______–______–______/______/______
Social Security Number Birth Date
Ø Race (please select):
White Black or African American American Indian/Alaskan Native
Asian Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native and White Asian and White Black/African American and White
American Indian/Alaskan Native and Black Other
Ø Ethnicity (please select “yes” or “no” for Hispanic Origin) Hispanic: Yes No
You should select both a “Race” category and a “yes” or “no” for Hispanic origin
Ø Immigrant Status (please select one):
You are U.S. born and 1 or both of your parents are foreign born
You are U.S. born but 1 or both grandparents foreign born
You are foreign born
You, your parents and grandparents are all U.S. born
Ø Marital Status: Single Married Divorced Separated Widowed
Ø Gender: Male Female
Ø Handicapped? Yes No
Ø Education (please select one):
Below High School Diploma High School Diploma or Equivalent
Two-Year College Bachelors Degree
Masters Degree Above Masters Degree
Ø Relationship to Applicant (please select):
Spouse Daughter Son Sister Brother
Girlfriend Boyfriend Mother Father Other:
CO-APPLICANT EMPLOYMENT — List ALL Employers for the Last 2 Years
Current Employer:
Street City State Zip Code
Title Supervisor
(______) ______–______Part-Time Full-Time
Phone Start Date
Starting Wage: $ hourly weekly every two weeks twice a month monthly
Current Wage: $ hourly weekly every two weeks twice a month monthly
Current Secondary Employer:
Street City State Zip Code
Title Supervisor
(______) ______–______Part-Time Full-Time
Phone Start Date
Starting Wage: $ hourly weekly every two weeks twice a month monthly
Current Wage: $ hourly weekly every two weeks twice a month monthly
Previous Employer:
Street City State Zip Code
(______) ______–______
Title Phone
Part-Time Full-Time
Start Date End Date
Starting Wage: $ hourly weekly every two weeks twice a month monthly
Ending Wage: $ hourly weekly every two weeks twice a month monthly
Why did you leave?
(Continue listing previous employers on a separate sheet of paper)
INCOME Please Print Clearly
APPLICANT / CO-APPLICANTType of Income / Gross Monthly Amount / Gross Monthly Amount
Salary
Alimony/ Child Support
Rental Income
Social Security
SSI
Pension Income
Public Assistance
Self-Employment Income
Disability Income (VA, etc…)
Other Employment
Unemployment
Other Income
Totals
APPLICANT CO-APPLICANT
Ø Can you document your child support/alimony income? Yes No Yes No
If yes, how long will it continue?
Ø If your child or a family member receives SSI,
how many more years will the payments continue?
Ø If you receive disability income, is it for a permanent disability? Yes No Yes No
Ø Regarding other employment, have you worked
in this field for two years or more? Yes No Yes No
LIABILITIES/DEBT
Please list any debts you have, including credit cards, auto loans, student loans, and child-care expenses. Do NOT include rent or utilities.
Paid To / Current Balance / Monthly Payment / Who’s Debt?A=Applicant
C=Co-Applicant
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Totals
Please use additional sheets if necessary.
APPLICANT CO-APPLICANT
Over the past three years, have you made your payments on time? Yes No Yes No
Are you currently in Chapter 13 bankruptcy? Yes No Yes No
If yes, when did it begin?
If yes, when will it be paid out?
If yes, how much is the payment? $
Have you had a Chapter 7 bankruptcy? Yes No Yes No
If yes, when was it discharged?
LIQUID FUNDS/SAVINGS/INVESTMENTS Please Print Clearly
Please list the approximate value of the following:
APPLICANT / CO-APPLICANTChecking Account
Savings Account
Cash
Certificates of Deposit
Securities (Stocks, bonds, etc…)
Retirement Account
Other Liquid Funds
Totals
Are you about to receive additional funds (e.g., tax refunds, property sales, etc.)? Yes No
If yes, how much? $
Do you currently have 1% of the construction price or $1,000.00 available for the downpayment? Yes No
LIVING EXPENSES
APPLICANT / CO-APPLICANTCurrent Monthly Rent or Mortgage
Electric/ Gas/ Trash
Telephone
Cellular/ Pager
Cable/ Satellite TV
Other Living Expenses
Totals
ADDITIONAL INFORMATION
APPLICANT CO-APPLICANT
Have you owned a home in the last three (3) years? Yes No Yes No
Are you a Veteran? Yes No Yes No
Do you have a contract on a house at this time? Yes No Yes No
Are you currently working with a real-estate agent? Yes No
Most convenient time for an individual appointment? AM PM
AUTHORIZATION
I authorize the Housing Authority of Texarkana Texas 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 the lender who made me/us a 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 civil liability and/or criminal liability under the provisions of Title 18, United States Code, and Section 1001.
______
Applicant Date
______
Co-Applicant Date
Home Ownership Applicant Intake Form – P. 4 HATT 2.0 Rev 6/14