Ramp Up Victoria Application

Ramp Up Victoria Application
Household & Applicant Information
Do you expect to move within the next year?
Applicant (Legal Name)
Applicant Birth Date

MonthDayYear
Date
Applicant Disabled?
If Applicant Disabled, please describe.
Applicant Email
example@example.com
Applicant Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Co-Applicant (Legal Name)
Co-Applicant Birth Date

MonthDayYear
Date
Co-Applicant Disabled?
If Co-Applicant Disabled, please describe.
Co-Applicant Email
example@example.com
Co-Applicant Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Other Household Residents
Did you or anyone in your household serve or is currently serving in the military?
Property / Home Information
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Home Unit #
Home City
Home State
Home Zip Code
Home Country
Was the home built before 1978?
Are there other listed owners besides the applicant and co-applicant?
Legal name(s) of additional owner(s)
Household Income

Please indicate an amount and if you are paid weekly (W), bi-weekly (BW), bi-monthly (BM), monthly (M), or annually (A).

Rows	Applicant	Interval of Payment	Co-Applicant	Interval of Payment	Others Members	Interval of Payment
Gross Wages
Overtime, Tips, Bonuses
Supplemental Security Income (SSI)
Social Security Disability (SSDI)
Pensions, Retirement, Veterans Benefits (Veterans Affairs), etc.
Child Support Income/ Alimony
Business Net Income
Rental/Real Estate Income
Welfare Payments (TANF)
Other
totals

Please indicate an amount and if you are paid weekly (W), bi-weekly (BW), bi-monthly (BM), monthly (M), or annually (A).

Rows	Applicant	Co-Applicant	Others Members
Checking
Savings
Cash/Bank Card
401K Retirement
Stocks/Bonds/Mutual Funds.
Other Property Owned
Other Accounts
Life Insurance
Vehicles (other than main vehicle)
Money Market
Total Assets

Rows	Monthly Payment (Applicant)	Monthly Payment (Co-Applicant)
Mortgage
Homeowner’s Insurance
Electricity
Water/Sewer
Natural Gas
Child Support
Alimony

SHARING PERSONAL INFORMATION
Is there anyone you would like to authorize us to communicate with on your behalf regarding your project and information? (case worker, health navigator, friend, relative, etc.)?
Authorized Contact Name
Authorized Contact Relationship
Authorized Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Contact Email
example@example.com
I give the GCHFH my consent to share my application/project with the person listed above.
Signatures
Applicant Signature
Applicant Signature Date

MonthDayYear
Date
Co-Applicant Signature
Co-Applicant Signature Date

MonthDayYear
Date
Office Use Only
Date Received

MonthDayYear
Date
Reviewed by GCHFH
Date Reviewed (GCHFH)

MonthDayYear
Date
Reviewed by COV
Date Reviewed (COV)

MonthDayYear
Date
Should be Empty: