Homeowner Intake Form

Habitat for Humanity Calaveras Homeownership Program Intake Form for Eureka Oaks Subdivision

Please complete intake form and sign the Authorization to Release Information form.
DATE

MonthDayYear
Date
Potential Applicant Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Do you rent or own?
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Age
Are you a veteran?
Which of the following applies?

I am a US citizen.I am a Permanent Resident.
Income Sources and Amounts (indicate gross monthly income):
Wages
Social Security Income
Child Support
Pension/Retirement/401K
Alimony/Maintenance
Unemployment (seasonally rcvd)
Workers Compensation
SNAP/Public Assistance
Self Employment
Other

Potential Applicant(s) Debts and Obligations

	Monthly	Balance
If over 62 or a person with a disability Ongoing medical expense (insurance, prescriptions, equipment, etc.)

Assets of all Household Members

Please describe your current housing situation and conditions Include any unsafe or unhealthy living conditions, rent costs exceeding 30% of your income, overcrowded living environment, inadequate utilities etc...
How would you rate your credit?

Absolutely Perfect (no late payments)Very good (a few late payments long ago)Pretty Good (a few late payments recently)Not Great (multiple missed payments)Pretty Bad (past due items or collections)Bad (recent bankruptcy, foreclosure, or unpaid judgment)
If you have adverse credit issues, tell me about why it happened and what you have done to correct it:
If you are unsure what your credit history contains, you can obtain a free credit report by calling. 1-877-322-8228 or logging into http://www.annualcreditreport.com. By law, individuals are entitled to receive one free credit file disclosure every 12 months from each of the nationwide consumer credit reporting companies: Equifax, Experian, and TransUnion.
Should be Empty:

Habitat for Humanity Calaveras Homeownership Program Intake Form for Eureka Oaks Subdivision