pROGRAM ELIGIBILITY ASSESSMENT for Housing
DEAR pROGRAM ELIGIBILITY ASSESSMENT APPLICANT: To determine if you are eligible for the Habitat for Humanity homeownership program please fill out this Program Eligibility Assessment application as completely and accurately as possible. All information you include on this application will be kept confidential.1. pROGRAM ELIGIBILITY ASSESSMENT APPLICANT INFORMATION
Applicant / Co-Applicant
Applicant’s Name: / Co-Applicant’s Name:
Social Security Number: / Date of Birth: / Social Security Number: / Date of Birth:
Day Phone #: / Evening Phone #: / Day Phone #: / Evening Phone #:
Email Address (if applicable): / Email Address (if applicable):
Current Address:
City State Zip Code
Mailing Address (if different from above):
City State Zip Code
Status / Status
U.S. Citizen Yes No / U.S. Citizen Yes No
Permanent Resident Yes No / Permanent Resident Yes No
Temporary Resident Yes No / Temporary Resident Yes No
Married (incl. Common Law) Yes No Date: / Married (incl. Common Law) Yes No Date:
Divorced Yes No / Divorced Yes No
Separated Yes No / Separated Yes No
Other (single, widowed, etc.) Yes No / Other (single, widowed, etc.) Yes No
What is your primary (first) language? / Are you able to speak/read English? Yes No
If no, please provide the name and phone number of a friend or relative who can translate for you.
Translator Name: Translator Phone Number:
*Qualification information
Citizenship: In order to meet qualifications, applicant(s) must be a permanent resident or must have already applied for residency.
Other Household Members (people who currently live with you and will live in the Habitat house with you if approved)
Employed
(Yes/No) / Name / Relationship / Age / Male or
Female / Income
1.
2.
3.
4.
5.
6.
7.
You MUST provide documentation for all household members who earn an income. Attach to application.
Have you applied for the Habitat homeownership program before? Yes No If yes, when and with which Habitat affiliate?
We are pledged to the letter and spirit of U.S. policy for the achievement of equal housing opportunity throughout the nation. We encourage and support an affirmative advertising and marketing program in which there are no barriers toobtaining housing because of race, color, religion, sex, handicap, familial status, sexual orientation, age, gender identity or national origin.
2. PRESENT HOUSINGDo you Rent or Own?
How long at current address? ______Years _____Months
Rent Information
What is your monthly rent payment? $______
If living at present address for less than two years complete the following:
Last Address:
SUBSIDIZED HOUSING INFORMATION
Do you currently live in subsidized housing? Yes No Amount Housing Agency Pays ______
If yes, please answer the following questions. If no, please continue to the next section.
Public Housing Agency:______Portion of Rent You Pay ______
Phone Number: ______Fax Number: ______
3. EMPLOYMENT HISTORY
APPLICANT / CO-APPLICANT
CURRENT EMPLOYER #1
Name & Address of CURRENT Employer:
From: (month/year): ______To:______
Monthly Gross Wage: $______/ CURRENT EMPLOYER #1
Name & Address of CURRENT Employer:
From: (month/year): ______To:______
Monthly Gross Wage: $______
Job Description: / Job Description:
Type of Business: / Type of Business:
Supervisor Name: / Phone #: / Supervisor Name: / Phone #:
*Qualification Information: In order to meet qualifications, applicant(s) must have at least one continuous year of employment history in the same industry.
CURRENT EMPLOYER #2 (if applicable)
Name & Address of CURRENT Employer:
Hire Date (mo/day/yr): ______
Monthly Gross Wage: $______/ CURRENT EMPLOYER #2 (if applicable)
Name & Address of CURRENT Employer:
Hire Date (mo/day/yr): ______
Monthly Gross Wage: $______
Job Description: / Job Description:
Type of Business: / Type of Business:
Supervisor Name: / Phone #: / Supervisor Name: / Phone #:
Pleaseexplain any gaps in employment history here (If needed attach page of additional information).
4. Monthly Income
Gross Monthly Income / Applicant / Co-Applicant / Adults in Household*
GrossEmployment Income (gross is before deductions) / $ / $ / $
AFDC/TANF (Cash Assistance)
AFDC/TANF Start Date:
Disability
Social Security
SSI
Alimony
Child Support
Other (explain)
Other (explain)
TOTAL / $ / $ / $
If any of the ADULTS in the household who earn an income are students, please complete the following:
Name / Amt of Income
Given to Household / Amount of Income
Given to School Expenses
$ / $
$ / $
$ / $
5. MONTHLY EXPENSES & LIABILITIES
LIABILITIES (Debts you owe)
List and attach any additional liabilities on a separate sheet of paper.
Original Balance / Current Balance / Monthly Payments
Auto Loan: / $______/ $______/ $______
Credit Card: / $______/ $______/ $______
Credit Card: / $______/ $______/ $______
Student Loan: / $______/ $______/ $______
Other (______):
Other (______):
Child Support:
Alimony Pmt:
Utilities
Natural Gas:
Water:
Garbage:
Electricity: / $______
$______
$______
$______
$______
$______/ $______
$______
Cell Phone:$______Car Insurance: $______
Cable:$______
Other:$______/ $______
$______
$______
$______
Total Liabilities: $______
6. DECLARATIONS
Please check the box that best answers the following questions for you and the co-applicant.
Applicant / Co-Applicant
1. Do you have any debt because of a court decision against you? / Yes No / Yes No
2. Have you been declared bankrupt within the past 7 years? / Yes No / Yes No
3. Have you ever had property foreclosed within the past 7 years? / Yes No / Yes No
4. Have your wages or bank accounts been garnished in the last 7 years? / Yes No / Yes No
5. Are you currently involved in a lawsuit? / Yes No / Yes No
6. Have you owned a home in the past three years? / Yes No / Yes No
*Answering “yes” to any of the above questions does not automatically disqualify you. However, if you answered “yes” please explain on an attached piece of paper.
7. Assets
Do you own land or any other real property? Yes No (If yes, please describe including location)
Is there a mortgage on the land? Yes No / If yes: Monthly payment $ Unpaid Balance $
Do you own a car? Yes No
Car #1) Make and Year / Car #2) Make and Year
Do you own any additional assets (for example: additional vehicles, jewelry, stocks, bonds, money market funds, etc.) Yes No If yes, please describe:
8. Willingness to Partner
To be considered for a Habitat home, you and your family must be willing to complete 500 “sweat equity” hours. Your help in building your home and the homes of others is called “sweat equity” and may include clearing the lot, helping with construction, working in the Evergreen Habitat office, education classes, or other approved activities.
Applicant / Co-Applicant
I am willing to complete the required sweat equity hours. / Yes No / Yes No
My family and I will use home as principal residence. / Yes No / Yes No
9. Authorization and release
I understand that by filing this Program Eligibility Assessment application, I am authorizing Habitat for Humanity to evaluate my actual need for a Habitat home, my ability to repay the no-interest loan and other expenses of homeownership and my willingness to be a partner family. I understand that the evaluation will include personal visits, a credit check and employment verification. I have answered all the questions on this Program Eligibility Assessment application truthfully. I understand that if I have not answered the questions truthfully, my Program Eligibility Assessment application may be denied, and that even if I have already been selected to receive a Habitat home, I may be disqualified from the program. I also understand that this is a non-mandatory, nonbinding Program Eligibility Assessment application and does not guarantee qualification. The original or a copy of this Program Eligibility Assessment application will be retained by Habitat for Humanity even if the it is not approved.
X______X______
Applicant Signature Date Co-Applicant Signature Date
10. INFORMATION FOR GOVERNMENT MONITORING PURPOSES
Please Read This Statement Before Completing the Box Below: The following information is requested by the federal government for loans related to the purchase of homes in order to monitor the lender’s compliance with equal credit opportunity and fair housing laws. You are not required to furnish this information, but are encouraged to do so. The law provides that a lender may neither discriminate on the basis of this information, nor on whether you choose to furnish it or not. However, if you choose not to furnish it, under federal regulations this lender is required to note race and sex on the basis of visual observation or surname. If you do not wish to furnish the information below, please check the box below. (Lender must review the above material to assure that the disclosures satisfy all requirements to which the lender is subject under applicable state law for the loan applied for.)
APPLICANT / CO-APPLICANT
I do not wish to furnish this information / I do not wish to furnish this information
Race/National Origin
American Indian or Alaskan Native
Native Hawaiian or other Pacific Islander
Black/African American
Caucasian
Asian
American Indian or Alaskan Native AND Caucasian
Asian AND Caucasian
Black/African American AND Caucasian
American Indian or Alaskan Native AND Black/African American
Other (specify) / Race/National Origin
American Indian or Alaskan Native
Native Hawaiian or other Pacific Islander
Black/African American
Caucasian
Asian
American Indian or Alaskan Native AND Caucasian
Asian AND Caucasian
Black/African American AND Caucasian
American Indian or Alaskan Native AND Black/African American
Other (specify)
Ethnicity
Hispanic Non-Hispanic / Ethnicity
Hispanic Non-Hispanic
Sex
Female Male / Sex
Female Male
Birth date: / / / Birth date: / /
Marital Status
Married
Separated
Unmarried (incl. single, divorced, widowed) / Marital Status
Married
Separated
Unmarried (incl. single, divorced, widowed)
Disabled
Yes No / Disabled
Yes No