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Townhome Features
Neighborhood Amenities
Live Here
Partners
Learn More
Townhome Features
Neighborhood Amenities
Live Here
Partners
Name
*
First Name
Last Name
Social Security Number or ITIN Number
*
Birth Date
MM
DD
YYYY
Home Phone
(###)
###
####
Cell Phone
(###)
###
####
Work Phone
(###)
###
####
Preferred Phone
Home
Cell
Work
Company
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date moved to this address
APPLICANT EMPLOYMENT
Information provided in this section is for the last 2 years
Primary Employer
Company
Company Phone
(###)
###
####
Title
Hire Date
Company Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Applicant works
Part-Time
Full-Time
Hours per week
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41 +
Gross Income
$
Hourly Rate
Amount Paid
Hourly
Weekly
Frequency
Every 2 weeks
Twice a month
Monthly
How did you hear about Green Country Habitat for Humanity?
What is your primary housing concern? (select all that apply)
Affordability
Space
Safety
House has a problem, not functional
Other
What would affordable homeownership mean to you and your family?
Have you tried to purchase a home before?
Yes
No
If yes, what were some of the barriers?
Current Housing Arrangement
Monthly Rent
Homeowner with mortgage
Homeowner with mortgage paid off
Living with a family member or friend
Homeless
Household Type
Single Mother
Single Father
Single without children
Two or more unrelated adults
Married with children
Married without children
Other
Household Size
1
2
3
4
5
6
7
8
9
10
11+
Annual Gross Household Income
$
Dependent Name - Birth Date - Relationship to Applicant
MONTHLY HOUSEHOLD INCOME
Income Source - Applicant (Monthly)
Salary
$
Alimony or Child Support
$
Social Security
$
Pension Income
$
Public Assistance
$
Self-Employment Income
$
Dependent SSI Income
$
Race
Select one
White
Black or African American
American Indian/Alaskan Native
Asian
Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native & White
Asian & White
Black/African American & White
American Indian/Alaskan Native & Black
Other
Ethnicity
Hispanic
Non Hispanic
Immigrant Status
Yes
No
Marital Status
Single
Married/Domestic Partner
Divorced
Separated
Gender
Male
Female
Transgender
Other
SPECIAL NEEDS AND PROGRAM QUESTIONS
Are you willing to attend financial education and/or credit counseling that provide education on how to avoid recurring debts that cannot be repaid through establishing an effective debt management plan or budget?
Yes
No
Are you willing to complete "sweat equity" hours volunteering for Green Country Habitat, either on your own home or at another site (construction, ReStore, offices, etc.)
Yes
No
Are you, or a member of your household, currently recovering from physical, alcohol or drug abuse?
Yes
No
Are you, or a member of your household, being treated for HIV or AIDS?
Yes
No
Have you, or any member of your household, served in the military, including National Guard and Reserves?
Yes
No
Are you, or any member of your household, disabled or handicapped (please include physical and mental disabilities?
Yes
No
**This information is private and protected by law and is only used for special programming requirements**
AUTHORIZATION
I authorize the housing Counseling Agency 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 a lender who made me/us 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 the civil liability and/or criminal liability under the provisions of Title 18, United States Code, Section 1001.
I understand
Date
MM
DD
YYYY
Thank you!
