Mi Casa First-Time Homebuyer's August 10th Class
Spanish American Committee Intake Form
Applicant/ Solicitante:
First Name/ Nombre
Last Name/ Apellido
Phone No.
Please enter a valid phone number.
Co Applicant/ Co-solicitante:
Social Security Number/Número de Seguro Social:
Birthday/ Fecha de nacimiento:
Gender/Género:
Male
Female
Address/ Dirección:
Street Address/ Calle
Street Address Line 2
City/ Cuidad
State / Province/ Estado
Postal / Zip Code/ Código postal
Phone Number/ Número de teléfono:
Please enter a valid phone number.
Email
*
example@example.com
Marital Status/ Estado civil:
Single
Married
Widowed
Seperated
Divorced
Race/ Raza
Hispanic/Latino
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian
Other Pacific Islander
White
Are you registered to vote? / ¿Estás registrado para votar?
Yes
No
Are you a U.S. Citizen?/¿Eres ciudadano/a de los Estados Unidos?
Yes
No
Country/ País:
Annual Income
Age Range/ Rango de edad:
15-19
20-34
35-54
55-64
65+
Services Requested/Servicios solicitados:
Social Services
Workforce/Employment
Housing
Financial Literacy
Legal Services (Housing)
English Classes/ ESOL
Other
Level of Education/Nivel de educación?
Please Select
Have not completed HS/GED
High School Diploma or GED
Vocational Certificate
Associate's Degree
Bachelor's Degree
Masters/Doctoral Degree
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Household Information/ Información del hogar
Current Housing Situation/ Situación de vivienda actual:
Please Select
Rent
Own Home
Living with Family
Homeless
Are you delinquent on your mortgage/ ¿Estás en mora con tu hipoteca?
Please Select
Yes
No
Number of Adults in Household/ Número de adultos en el hogar?
Please Select
1
2
3
4
5
6
Number of children in Household age 5-18 / Número de niños en el hogar de 5 a 18 años?
Please Select
1
2
3
4
5
6
7
8
Number of children in Household under age 5/ Número de niños en el hogar menores de 5 años?
Please Select
1
2
3
4
5
6
Are you currently employed? / ¿Estás actualmente empleado/a?
Yes
No
Name of Employer/ Nombre del empleador
Start Date:
-
Month
-
Day
Year
Date
Yearly Salary/ Hourly Rate/ Salario/Tarifa por hora:
Co-Applicant's Employer/ Empleador del co-solicitante:
Start Date
-
Month
-
Day
Year
Date
Yearly Salary/ Hourly Rate/ Salario/Tarifa por hora:
Do you receive public assistance? / ¿Recibes asistencia pública?
Yes
No
Do you have health insurance?/ ¿Tienes seguro de salud?
Yes
No
Do you have your own transportation? /¿Tienes transporte propio?
Yes
No
Have you ever been convicted? /¿Alguna vez has sido condenado/a?
Yes
No
Are you a veteran? /¿Eres veterano/a?
Yes
No
Do you have children in school? / ¿Tienes niños en la escuela?
Yes
No
Do you need food in your home? / ¿Necesitas alimentos en tu hogar?
Yes
No
Government Identification
*
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How did you hear about this class? / ¿Cómo se enteró de este curso?
I saw it on Social Media/ Lo vi en redes sociales
A friend recommended it to me/ Me lo recomendó un amigo.
I saw it advertised on Spanish American Committee's Website/ Lo vi anunciado en el sitio web del Comité Hispano Americano
I found out through a poster or flyer/ Me enteré a través de un afiche o cartel
Form will be completed in person with signature.
El formulario se completará en persona con firma.
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