ABWK & CHR Programs

ABWK & CHR Programs

Pre-Screening Questionnaire
Date:*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone:*

Area CodePhone Number
HomeWorkCellOther
Have you had a steady income in the U.S. for at least 2 years (disability and child support count)?*

YesNo
Do you own your home?*

YesNo
Do you own the property of which your home is located?*

YesNo
Have you owned your home for three years or longer? (If you answer no, you are not eligible for any repair programs with BWHFH, please contact us when you meet this requirement.)*

YesNo
Have you applied and been discharged from bankruptcy in the last 2 years?*

YesNo
If you are a Veteran can you access Form DD 214 or other proof of general or honorable discharge?*

YesNo
Who is your Main employer?*
How long have you worked here?*
years
Are you full time or part time?*

Full TimePart Time
Number of hours worked each week*
Pay rate:*
The pay rate is:*

HourlyWeeklyEvery other week2 times per monthMonthlyYearly
Co-Applicant Information:

If no Co-Applicant, please move on to the next section.
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone:

Area CodePhone Number
HomeWorkCellOther
Have you had a steady income in the U.S. for at least 2 years (disability and child support count)?

YesNo
Do you own your home?

YesNo
Have you applied and been discharged from bankruptcy in the last 2 years?

YesNo
If you are a Veteran can you access Form DD 214 or other proof of general or honorable discharge?

YesNo
Who is your Main employer?
How long have you worked here?
years
Are you full time or part time?

Full TimePart Time
Number of hours worked each week
Pay rate:
The pay rate is:

HourlyWeeklyEvery other week2 times per monthMonthlyYearly
Additional Household Income

(Monthly)
OTHER Applicant Employment:*
OTHER Co-Applicant Employment:
Social Security, SSI and/or Disability*
Child Support (Friend of the Court) Food Stamps:*
Other Income*
Monthly Debt Expenses for Applicant and Co-Applicant
Mortgage Amount:
Car Payment (s):*
Credit Card Payments:*
Child Support Payments*
Student Loan Payments*
Repair Needed:
Briefly describe the repair(s) or accessibility needed:*
Have you previously applied to any other organizations for assistance?*

YesNo
If yes, which organization and what was the outcome?
Your willingness to Partner with Blue Water Habitat for Humanity:

If your family is selected are you willing to meet the requirements for Habitat Partner Families, including:
- Attend a Money Management class provided by an agent of BWHFH’s choice.
- Attend home maintenance classes if required.
- Assist EVERY DAY during the repair work done on your home. (Special circumstances considered)
- Be a good ambassador for Habitat in the community so this important work can continue.
Yes, I am willing to meet these requirements if selected.No, I am not willing to meet these requirements.
How did you hear about the Habitat for Humanity Program?

Friend of a family memberInternetTV, Newspaper, MagazineAnother AgencyHabitat Homeowner/Partner FamilyOther
By signing and submitting this questionnaire, I/we request consideration for making application to the Blue Water Habitat for Humanity A Brush with Kindness or Critical Home Repair programs. By signing this document I am also aware that you will check my name on the National Sex Offender Checklist. If found, I understand this will automatically disqualify me from the program.
Applicant Signature

Clear
Date signed*

MonthDayYear
Date
Co-Applicant Signature

Clear
Date signed*

MonthDayYear
Date
Should be Empty:

ABWK & CHR Programs

Co-Applicant Information:

Additional Household Income

Monthly Debt Expenses for Applicant and Co-Applicant

Repair Needed:

Your willingness to Partner with Blue Water Habitat for Humanity: