This Is Not an Application, but an Initial Assessment of Eligibility for Habitat for Humanity
This is not an application, but an initial assessment of eligibility for Habitat for Humanity of Greater Los Angeles’ homeownership program. Please completely fill out this questionnaire and send to the Homeowner Relations Department by fax at (562) 863-8866, by email at or by mail to 17700 S. Figueroa Street, Gardena, CA 90248. Upon receipt, a representative from our affiliate will contact you to discuss next steps.
All of the information provided in your Homeownership Pre-Application Eligibility Questionnaire is confidential and will be kept strictly private. Only officially designated Habitat for Humanity of Greater Los Angeles staff and volunteers will be able to review this questionnaire and the information herein contained.
Please note this form will only be accepted from April 1, 2014 through April 30, 2014.
Contact Information
Main Applicant:First MI Last
Address (include Unit #) City/State Zip Code
City of employment:
Home Phone Number: / Cell Phone Number:
Best phone number to call: / Home Phone Number / Cell Phone Number
Email address (if available):
Household Size (including yourself):
Best day of the week to reach you: / Best time of day:
Language preference: / Special communication needs:
Household Monthly Income
(List all forms of income received by applicants and/or adult household members)
Type of Monthly Income / Main Applicant / Co-Applicant #1 or Household Member / Co-Applicant #2 or Household Member / Co-Applicant #3 or Household Member / Household Member
Wages/Salary
Net Business Income/ Net Self-Employment
Unemployment/Disability/Worker’s Compensation
Social SecurityBenefit
Supplemental Security Income (SSI)
Retirement/Pension
Military Income
Alimony
Child Support
Recurring Cash Payments
Total Monthly income: / $ / $ / $ / $ / $
Credit Information
Please answer the following questions regarding your credit:
- Do you have any credit accounts in collection?Yes: No: Not Sure:
If Yes, what is the type and amount in collections? Consumer Medical Amount: $
- Do you have any open judgments or liens? Yes: No: Not Sure:
If Yes, what is the judgment/lien amount?$
- Have you filed for bankruptcy in the past? Yes: No:
If Yes, what year was your bankruptcy settled?
How did you hear about Habitat for Humanity of Greater Los Angeles and its Homeownership Programs?
Church / Community /Civic Group / Habitat Homeowner / Habitat Website / Habitat Speakers Bureau / School / Work/Job Fair
City Hall / Family/Friend / Social Media/eNewsletter / Habitat Office/Restore / TV/Radio/ Newspaper / Other:
Optional Information: If you choose, please complete the following regarding your demographic information.This information is requested solely for statistical reporting purposes and remains confidential.
Disabled / Senior Citizen / Veteran / Widow of a Veteran / Active Military/Reservist
Ethnicity: / Hispanic / Non-Hispanic
Racial Background:
White / Black/African American / Asian / American Indian/Alaskan Native / Native Hawaiian/Other Pacific Islander
Black/African American & White / American Indian/Alaskan Native & White / Asian & White / American Indian/Alaskan Native & White / Other:
FOR OFFICE USE ONLY
Date Received / Household Size / Gross Annual Income / Total Debt / Eligibility (Y/N) / Staff/Volunteer Name / Date Entered
Habitat for Humanity of Greater Los Angeles provides equal housing opportunities for all, and ensures fair and equal access to its programs and services regardless of race, color, religion, gender, national origin, familial status, disability, marital status, ancestry, sexual orientation, source of income, or other characteristics protected by law.