City of Fosston SCDP Homeowner Application

Small Cities Development Program
HOMEOWNER APPLICATION
CITY OF FOSSTON

Northwest Minnesota Multi-County HRA
PO Box 128 | Mentor, MN 56736 | Phone: 218-309-0057

The information on this application will be used to determine your eligibility for a Rehabiliation Loan. All fields must be completed.
APPLICANT INFORMATION
Full Name

First NameMiddle InitialLast Name
Birth Date

MonthDayYear
Birth Date
Social Security Number
Social Security Number
Marital Status
Race
Address

Street

Apt/Unit

CityState

Zip Code
Home Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Do you have a co-applicant to add to the application?
CO-APPLICANT INFORMATION
Full Name

First NameMiddle InitialLast Name
Birth Date

MonthDayYear
Birth Date
Social Security Number
Social Security Number
Marital Status
Race
Address

Street

Apt/Unit

CityState

Zip Code
Home Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
OTHER HOUSEHOLD OCCUPANTS

Please provide the following information for each member of the household NOT listed as the applicant or co-applicant
How many other household occupants, not including the applicant and co-applicant, do you have to add to the application?
Household Member #1
Name

First NameLast Name
Birth Date

MonthDayYear
Birth Date
Race
Household Member #2
Name

First NameLast Name
Birth Date

MonthDayYear
Birth Date
Race
Household Member #3
Name

First NameLast Name
Birth Date

MonthDayYear
Birth Date
Race
Household Member #4
Name

First NameLast Name
Birth Date

MonthDayYear
Birth Date
Race
Household Member #5
Name

First NameLast Name
Birth Date

MonthDayYear
Birth Date
Race
INCOME INFORMATION

"Income" means any amount received from the following sources by ANY member of the household age 18 or over.
Does anyone in the household receive Public Assistance including: MFIP, SSI, GA, Child Support, and Unemployment Compensation?
Does anyone in the household earned a salary including: wages, commissions, bonuses, tips, and overtime pay?
Does anyone in the household receive estate or trust income?
Does anyone in the household receive rental income?
Does anyone in the household receive gains from the sale of property or securities?
Does anyone in the household receive income from pensions or annuities including: PERA, Social Security, and Railroad Retirement?
Does anyone in the household receive income from business profit (for self-employed individuals, including farmers)?
Does anyone in the household receive income from interest and dividends?
Does anyone in the household receive contract for deed payments?
Does anyone in the household receive child support or alimony?
Applicant's Employer is:
Co-Applicant's Employer is:
How many incomes do you have to list?
INCOME #1
Name of Household Member
Annual Income Amount
Source of Income
**Attach proof/copies of income at the end of application
INCOME #2
Name of Household Member
Annual Income Amount
Source of Income
**Attach proof/copies of income at the end of application
INCOME #3
Name of Household Member
Annual Income Amount
Source of Income
**Attach proof/copies of income at the end of application
INCOME #4
Name of Household Member
Annual Income Amount
Source of Income
**Attach proof/copies of income at the end of application
INCOME #5
Name of Household Member
Annual Income Amount
Source of Income
**Attach proof/copies of income at the end of application
PROPERTY INFORMATION
Do you have an outstanding mortgage on the property?
What is the outstanding principal on the mortgage?
Do you have any outstanding Contracts for Deed on the property?
What is the outstanding principal on the contract?
Do you have a life estate deed?
What type of house is it?
How many years have you lived in the house?
What year was the house built?
What is the current estimated value (from your most recent property tax statement) of the property to be improved?
Do you have homeowner's insurance?
Are there unpaid property taxes on this property?
Before continuing, please click the following links and read through the information:
- Fair Housing Act of 1966
- Protect Your Family From Lead in Your Home
Please read and check each box by the following statements
Applicant's Signature
Date

MonthDayYear
Date
Co-Applicant's Signature
Date

MonthDayYear
Date
WARNING: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and willingfully makes or uses a document or writing containing any false, fictious statement or entry, in any matter within the jurisdiction of any department or agency of the United States shall be fined no more than $10,000 or imprisoned for not more than five (5) years, or both.
File Upload

The following items MUST be submitted with the application. You can either submit them below or email them to kristi@nwmnhra.org.
Last three (3) paystubs/last filed income tax

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Proof of any other income listed

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Copy of insurance declaration page

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Copy of mortgage or satisfied mortgage document

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Proof of current property taxes & copy of property tax statement

Cancelof
Should be Empty:

APPLICANT INFORMATION

CO-APPLICANT INFORMATION

OTHER HOUSEHOLD OCCUPANTS

INCOME INFORMATION

PROPERTY INFORMATION

Please read and check each box by the following statements

File Upload