Full Client Application Form

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Date of Birth*
MM slash DD slash YYYY
Do you live in Tillamook County?*
- Yes
- No
Do you own your home?*
- Yes
- No
Is your home paid off?*
- Yes
- No
Do you own the land your home is on?*
- Yes
- No
Is this your primary residence?*
- Yes
- No
Are you current on your property taxes and homeowner’s insurance?*
- Yes
- No
Are you in danger of losing your home or being foreclosed?*
- Yes
- No
Are there any judgments or liens against you or on the property?*
- Yes
- No
How many months out of the year do you live in the home listed above:*
Please enter a number from 1 to 12.
Do you plan on staying in this home for at least three years?*
- Yes
- No
Type of home:*
- Built on-site
- Mobile
List the name, ages and relationship of ALL household residents below:
Name Relationship Age
Is anyone in the household a veteran?*
- Yes
- No
Is anyone in hour household currently in the military?*
- Yes
- No

Special Needs
Are you, or is any member of your household:
A senior citizen?*
- Yes
- No
A person with disabilities?*
- Yes
- No
Does the homeowner or anyone living in the home have a disability that would affect his or her ability to help perform work on the home?*
- Yes
- No
Are there pets in the home?*
- Yes
- No
Number/types:*

Household Income
The total, combined income before taxes for ALL persons living in the home is: $________________ per year.*
Wages:
Child Support:
Pension/Retirement:
Social Security:
Permanent Disability:
Alimony:
Other:
For instance, the most recent income tax return, monthly social security statement, other retirement income statements, employment check stub. Please note on attached statements frequency of income).
Is anyone in the household currently employed?*
- Yes
- No
Please list names of employee(s), employer(s) and the city/state of the employer(s):
If you have declared bankruptcy, indicate the date it was discharged:
MM slash DD slash YYYY
Name of bank, savings and loan, credit union, etc. Address Account Number Current Balance ($)
Mortgage Payment:
Medical/Dental:
Lot rental:
HOA Dues:
Car payment:
Child/Spousal Support:
Utilities:
Child Care:
Cell Phone:
Business Expenses:
Student loans:
Motor Vehicle
Is asset paid off:
- Yes
- No
Unpaid Balance:
Months left to pay
Additional Motor Vehicle
Is asset paid off:
- Yes
- No
Unpaid Balance:
Months left to pay
Boats
Is asset paid off:
- Yes
- No
Unpaid Balance:
Months left to pay
Motorcycle(s)
Is asset paid off:
- Yes
- No
Months left to pay
Months left to pay
Credit Card
Type $

Family Background
Are you or any member of your household required to register as a sex offender in any state?*
- Yes
- No
In which state is this registration?*
Habitat for Humanity screens all potential applicants on the National Sex Offender Public Registry.

Repairs Needed
In this section, please describe the type of work you would like done on your home. Attach a separate piece of paper if there is not enough space to list all repairs. Remember that the items listed below will be considered for repair, but the final decision on what work can be done with our time and financial resources will be made at the discretion of our Ramps & Rails Committee.
House painting. Please describe:
Minor siding and trim repair. Please describe:
Board replacement in porch, stair, or ramps. Please describe:
Yard work (including pruning, trimming, weeding). Please describe:
Junk removal. Please describe:
Critical Home Repairs (CHR): Please describe any further repairs that may be necessary.

By completing this application, I certify that the information I have provided on this application is accurate and that I own the property at the address provided. I have no present intention to move or offer my home for sale for at least three years. I confirm that, except for the conditions listed in this application, my home is a safe place for volunteers.

Completion of this application signifies that I understand that if I am approved and there are costs for the repairs, I agree to pay for the cost of the repairs and may be able to qualify for a no interest loan for those costs and make monthly payments until the balance is paid off.

I understand that the people who may work on my house may be unpaid volunteers or staff; that few, if any are skilled in the building trades, and that ‘Ramps & Rails’ makes NO WARRANTIES, EXPRESSED OR IMPLIED REGARDING ANY MATERIALS USED OR WORK DONE BY ANYONE AT MY HOUSE.

I understand that the people who may work on my house may be unpaid volunteers or staff; that few, if any are skilled in the building trades, and that ‘Ramps & Rails’ makes NO WARRANTIES, EXPRESSED OR IMPLIED REGARDING ANY MATERIALS USED OR WORK DONE BY ANYONE AT MY HOUSE.

I also understand that Habitat for Humanity screens all applicant families on the sex offender registry. By completing this application, I am submitting myself to such an inquiry. I further understand that by completing this application, I am submitting myself to a criminal background check.

I hereby release Tillamook County Habitat for Humanity and any of its affiliated organization from all actions, claims or demands that I, my assignees, heirs, guardians, and legal representatives now have or may hereafter have for injury or damages resulting from my participation in any Tillamook County Habitat for Humanity activities.
By completing this application, I certify that the information I have provided on this application is accurate and that I own the property at the address provided. I have no present intention to move or offer my home for sale for at least three years. I confirm that, except for the conditions listed in this application, my home is a safe place for volunteers.
Completion of this application signifies that I understand that if I am approved and there are costs for the repairs, I agree to pay for the cost of the repairs and may be able to qualify for a no interest loan for those costs and make monthly payments until the balance is paid off.

I understand that the people who may work on my house may be unpaid volunteers or staff; that few, if any are skilled in the building trades, and that ‘Ramps & Rails’ makes NO WARRANTIES, EXPRESSED OR IMPLIED REGARDING ANY MATERIALS USED OR WORK DONE BY ANYONE AT MY HOUSE.

I understand that the people who may work on my house may be unpaid volunteers or staff; that few, if any are skilled in the building trades, and that ‘Ramps & Rails’ makes NO WARRANTIES, EXPRESSED OR IMPLIED REGARDING ANY MATERIALS USED OR WORK DONE BY ANYONE AT MY HOUSE.

I also understand that Habitat for Humanity screens all applicant families on the sex offender registry. By completing this application, I am submitting myself to such an inquiry. I further understand that by completing this application, I am submitting myself to a criminal background check.
- I hereby release Tillamook County Habitat for Humanity and any of its affiliated organization from all actions, claims or demands that I, my assignees, heirs, guardians, and legal representatives now have or may hereafter have for injury or damages resulting from my participation in any Tillamook County Habitat for Humanity activities.

Full Client Application Form

Step 1 of 7

Special Needs

Household Income

Family Background

Home Information

Repairs Needed

Name	Relationship	Age

Name of bank, savings and loan, credit union, etc.	Address	Account Number	Current Balance ($)

Type	$