Wilma's Hope Online Application

Important Note: The applicant(s) understands that this in-take application is a screening document to ensure that potential applications meet the minimum requirements. This in-take application does not guarantee that the applicant will qualify for the program.
I. Applicant Information
Date of Application

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Applicant's Full Name
First, Last
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Address
Street Address
City
State, Zip code
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Gender
Marital Status
Ethnicity
Current Gross Monthly Income
Please type "0" if no income
Employment Status
Current Employer
If unemployed, please specify
Current Occupation
Date/From

MonthDayYear
2 digit month, 2 digit day, 4 digit yearFirst date of employment
Date/To

MonthDayYear
2 digit month, 2 digit day, 4 digit yearLast date of employment/If currently still employed, please choose today's date.
Employer Address
Address, City, State, Zip code
Employer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
*If employed in current position less than two (2) years or if currently employed with more than one employer, please complete the following:
Employer Name
Occupation
Date/From

MonthDayYear
2 digit month, 2 digit day, 4 digit yearFirst date of employment
Date/To

MonthDayYear
2 digit month, 2 digit day, 4 digit yearLast date of employment
Employer Address
Address, City, State, Zip code
Employer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
II. Co-Applicant Information

If Applicable
Co-Applicant's First Name
Co-Applicant's Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Address, City, State, Zip code
Current Gross Monthly Income
Employment Status
Current Employer
If unemployed, please specify
Current Occupation
Date/From

MonthDayYear
2 digit month, 2 digit day, 4 digit yearFirst date of employment
Date/To

MonthDayYear
2 digit month, 2 digit day, 4 digit yearLast date of employment/If currently still employed, please choose today's date.
Employer Address
Address, City, State, Zip code
Employer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
III. Applicant Declarations:
Select all that apply:
IV. Household Occupant Information:

Additional persons living in the household exclude applicants

Please complete all that apply:

Rows	Full Name	Relationship	Age	M/F	Employed? Y/N	Gross Monthly Income	Source of Income
Occupant 1
Occupant 2
Occupant 3
Occupant 4

If no additional household occupants:
Total Gross Household Income:
V. Additional Income:

Additional persons living in the household (Please exclude applicants)

Include all sources of income (i.e., pensions, child support, SSI, disability, alimony, etc. If no additional sources of income apply, please leave blank and complete the box below.

Rows	Source of Income	Monthly Income
Income 1
Income 2
Income 3
Income 4
Income 5

Total Additional Household Income:
Modifications Requested: (All modifications require CNCS approval before work is executed)
Please Explain:
IMPORTANT - READ BEFORE SIGNING:

I/We certify that the above statements are true, accurate, and complete to the best of my/our knowledge and belief. I/We hereby authorize Going Global to verify the information contained in the above statements from any source whatsoever and hereby authorize and direct the release of such information. I/We hereby authorize photocopies of this form to be valid as the original.

PENALTY FOR FALSE OR FRAUDULENT STATEMENTS: U.S.C. Title 18, Sec. 1001, provides: Whoever in any matter within the jurisdiction of any department or agency of the United States Knowingly and willfully falsifies or makes any false, fictitious or fraudulent statements or representations or makes or uses any false writing or documents knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than 5 years or both.
EQUAL CREDIT OPPORTUNITY ACT

You are hereby provided the following "Equal Credit Opportunity Act": notice as prescribed under Section 202.4(d): "The Federal Equal Credit Opportunity Act" prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided that the applicant has the capacity to enter into a binding contract: because all or part of the applicant's income derives from any public assistance program, or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The Federal agency that administers compliance with this law concerning this creditor is the Federal Home Loan Bank Board, 111 E. Wacker Drive, Chicago, Illinois.
NOTICE OF APPLICANTS/RIGHT TO FINANCIAL PRIVACY ACT CERTIFICATION

This is notice to you as required by the "Right to Financial Privacy Act of 1978" that the Department of Housing and Urban Development (HUD) has a right of access to financial records held by any financial institution in connection with the consideration or administrator of all rehabilitation loans for which you have applied. Financial records involving your transactions will be available to HUD without further notice or authorization but will not be disclosed or released to another Government Agency or Department without your consent, except as required or permitted by law.
VI. Signatures
Applicant Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Co-Applicant Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Important Note: The applicant(s) understands that this in-take application is a screening document to ensure that potential applications meet the minimum requirements. This in-take application does not guarantee that the applicant will qualify for the program.

Please allow 2-3 Business days to process your application. A member of our staff will reach out to you reagrding your application. Please inform us if you need any assistance via the contact information below:

Email: cbass@goingglobal.org Phone: 931.542.2025
Should be Empty:

I. Applicant Information

II. Co-Applicant Information

III. Applicant Declarations:

IV. Household Occupant Information:

V. Additional Income:

VI. Signatures