Housing Rehab Annual Audit Form

Annual Audit Form for Deferred Loans

Due by February 15th of each year
Name:

First NameLast Name
Loan Number:
Property:
Loan Balance:
Home Phone #:

Area CodePhone Number
Cellphone #:

Area CodePhone Number
1. Is this address your primary residence?

YesNo
2. Do you legally own, or are buying the home?

OwnBuying
3. Name and age of each person living in the home?
4. What is the annual gross household income?
5. Name of Contact Person:
(Person not living with you)
6. Phone Number of Contact Person:

Area CodePhone Number
7. Name of homeowners Insurance Agency:
8. Insurance Policy #:
Signature*
Date*

MonthDayYear
Date
135 NE Dunn Place, McMinnville, OR 97128

PH 503-883-4300 FAX 503-472-4376

Toll Free 888-434-6571 TDD 800-735-2900

www.hayc.org

“Equal Housing Opportunity”
Should be Empty: