Independent Living Financial Info Form

Independent Living Financial Info Form

Clearview Home Corporation
Please complete this application and note the following:
- Exact figures are not required—reasonable estimates are acceptable.
- If any answers need more explanation, please write notes in the margins or on a separate sheet and share them during the phone interview.
Applicant Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Eligibility Considerations for renting
1) FEDERAL INCOME TAX RETURNS: Have you filed an IRS Form 1040? If so, please provide a copy of the first two pages, and email them to executivedir@clearviewhome.org or FAX to 1-262-646-4127.*

YesNo
2) HOME OWNERSHIP: Does the applicant own a home?*

YesNoOther
If yes, please provide the following:
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mortgage balance (rounded to nearest $1000, including any second mortgage): (Please also enter in the Total Liability section below)*
Monthly Mortgage payment (rounded to nearest $100, including any second mortgage): *
3) ASSETS - enter rounded to the nearest $1000; enter 0 if less than $1000
Cash and Checking Accounts*
Savings Accounts and CDs*
Stocks, bonds, and stock/bond funds*
Mutual funds*
Annuities*
Retirement accounts*
Cash value of life insurance*
Real estate (primary residence, rental vacation, business, etc.)*
Vehicles (automobiles, boats, RVs, etc)*
Other assets (art, collectibles, etc.)*
APPLICANT'S TOTAL ASSETS
4) Applicants Liabilities -- rounded to the nearest $1000
Mortgage Loan*
Home Equity Loan*
Auto Loan*
Credit Card Debt*
Other loans or debt*
APPLICANT'S TOTAL LIABILITIES
5) Applicants Monthly Income - Round to the nearest $100
Employment*
Business Income*
Pension*
Annuities*
Retirement account distributions*
Social Security*
Social Security Disability*
Other Income*
APPLICANT'S MONTHLY INCOME
6) Additional Documentation

Upon submission, you will receive an email stating whether additional documents are needed. These may include: additional IRS Form 1040, a durable or Financial Power of Attorney
Signature

I affirm that the information provided in this application is accurate to the best of my knowledge.
Signature*

Clear
Date*

MonthDayYear
Date
Any questions??? Contact:

Elizabeth F. Harned, Executive Director
Executivedir@clearviewhome.org
651-470-7816 (Mobile)
Clearview Home Corporation
935 Main Street
Delafield, WI 53018
262-646-3361

FAX - 262-646-4127
Should be Empty:

Independent Living Financial Info Form

Applicant Information

Eligibility Considerations for renting

3) ASSETS - enter rounded to the nearest $1000; enter 0 if less than $1000

4) Applicants Liabilities -- rounded to the nearest $1000

5) Applicants Monthly Income - Round to the nearest $100

6) Additional Documentation

Signature