Housing Application

Customer
Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Home
Mobile/Cell
Work
Fax
Email*
Social Security Number*
Birth Date*
Month
Day
Year

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Ethnicity/ Origin (please choose one):*
- Asian
- African American
- Hispanic/latino
- Native American
- Pacific Islander
- White
- 2 or more races
Immigrant Status (please select one):*
- You are U.S. born
- You are a Naturalized Citizen
- You are foreign born, and a U.S. Resident (green card holder)
Marital Status*
- Single
- Married
- Divorced
- Separated
- Widowed
Gender*
- Male
- Female
Disabled*
- Yes
- No
Current Housing Arrangement*
- Rent
- Homeless
- Living with family member and not paying rent
- Living with friends or roommates, sharing rent
Are you a first Time Buyer (you do not currently own a home and have not owned a home in the past three years)?*
- Yes
- No
Household Type (please select the most accurate)?*
- Female headed single parent household
- Male headed single parent household
- Single adult
- Two or more unrelated adults
- Married with children
- Married without children
- Other
Family/Household Size:
How many dependents (other than those listed by any co-borrower)?
What ages are they?
Are there non-dependents who will be living in the home?
- Yes
- No
List non-dependents below:
Relationship Age
Annual Family or Household Income
Education (please choose one):
- Below High School Diploma
- High School Diploma or Equivalent
- Two-Year College
- Bachelors Degree
- Masters Degree
- Above Masters Degree
Referred to by (please check all that apply):
- Print Advertisement / Newspaper
- Staff/Board member
- Bank
- Walk-In
- Government
- Family/Friend
- Habitat Partner
- TV/Radio
- Realtor
- Facebook
If you were referred by a bank, Habitat Partner or Realtor, which one?
With co-applicant*
- Yes
- No

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Customer Employment - Last 2 Years
Primary Employer*
Title
Hire Date
Month
Day
Year
Address
Street Address Address Line 2 City State ZIP Code
Phone
(Please Choose):
- Part-Time
- Full-Time
Gross Income (before taxes)*
Is this amount paid
- hourly
- weekly
- every two weeks
- twice a month
- monthly

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Previous Employer*
Title
Length of Employement
Address
Street Address Address Line 2 City State ZIP Code
Phone
(Please Choose):
- Part-Time
- Full-Time
Continue listing previous employers:
Previous Employer Title Length of Employment Street/City/State Phone Part-time/Full-time

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Secondary Employer
Title
Hire Date
Month
Day
Year
Address
Street Address Address Line 2 City State ZIP Code
Phone
(Please Choose):
- Part-Time
- Full-Time
Gross Income (before taxes)*
Is this amount paid
- hourly
- weekly
- every two weeks
- twice a month
- monthly

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Co-Applicant Employment - Last 2 Years
Primary Employer*
Title
Hire Date
Month
Day
Year
Address
Street Address Address Line 2 City State ZIP Code
Phone
(Please Choose):
- Part-Time
- Full-Time
Gross Income (before taxes)*
Is this amount paid
- hourly
- weekly
- every two weeks
- twice a month
- monthly

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Previous Employer
Title
Length of Employment
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
(Please Choose):
- Part-Time
- Full-Time
Continue listing previous employers:
Previous Employer Title Length of Employment Street/City/State Phone Part-time/Full-time

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Secondary Employer
Title
Hire Date
Month
Day
Year
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
(Please Choose):
- Part-Time
- Full-Time
Gross Income (before taxes)*
Is this amount paid
- hourly
- weekly
- every two weeks
- twice a month
- monthly

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Income
Salary*
CUSTOMER Monthly Amount CO-APPLICANT Monthly Amount
Alimony/Child Support
CUSTOMER Monthly Amount CO-APPLICANT Monthly Amount
Rental Income
CUSTOMER Monthly Amount CO-APPLICANT Monthly Amount
Social Security
CUSTOMER Monthly Amount CO-APPLICANT Monthly Amount
Pension Income
CUSTOMER Monthly Amount CO-APPLICANT Monthly Amount
Public Assistance
CUSTOMER Monthly Amount CO-APPLICANT Monthly Amount
Self-employment Income
CUSTOMER Monthly Amount CO-APPLICANT Monthly Amount
Dependent SSI Income
CUSTOMER Monthly Amount CO-APPLICANT Monthly Amount
Disability Income
CUSTOMER Monthly Amount CO-APPLICANT Monthly Amount
Other Employment
CUSTOMER Monthly Amount CO-APPLICANT Monthly Amount

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Liabilities/Debt
Please list any debts you have, including credit cards, auto loans, student loans, and child-care expenses. Do NOT include rent or utilities.
Paid to Current Balance Monthly Payment Who's Debt C=Customer,A=Co-Applicant, B=Both
CUSTOMER: Have your payments been made on time?
- Yes
- No
Are you currently in Chapter 13 bankruptcy?
- Yes
- No
If yes, when did it begin?
If yes, when will it be paid out?
If yes, how much is the payment?
Have you had a Chapter 7 bankruptcy?
- Yes
- No
If yes, when was it discharged?
CO-APPLICANT: Have your payments been made on time?
- Yes
- No
CO-APPLICANT: Are you currently in Chapter 13 bankruptcy?
- Yes
- No
If yes, when did it begin?
If yes, when will it be paid out?
If yes, how much is the payment?
CO-APPLICANT: Have you had a Chapter 7 bankruptcy?
- Yes
- No
If yes, when was it discharged?

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Liquid Funds/Savings/Investments
Please list the approximate value of the following:
Checking account
CUSTOMER CO-APPLICANT
Savings account
CUSTOMER CO-APPLICANT
Cash
CUSTOMER CO-APPLICANT
CDs
CUSTOMER CO-APPLICANT
Securities (stocks, bonds, etc.)
CUSTOMER CO-APPLICANT
Retirement account
CUSTOMER CO-APPLICANT
Other Liquid Funds
CUSTOMER CO-APPLICANT
Are you about to receive additional funds (e.g., tax refunds, property sales, etc.)?
- Yes
- No
If yes, how much?

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Living Expenses
Current monthly rent
CUSTOMER CO-APPLICANT
Electric/Gas/Solid Waste
CUSTOMER CO-APPLICANT
Telephone
CUSTOMER CO-APPLICANT
Cellular/Pager
CUSTOMER CO-APPLICANT
Cable/Satellite TV
CUSTOMER CO-APPLICANT
Other Living Expenses
CUSTOMER CO-APPLICANT

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I authorize the Tillamook Habitat for Humanity Staff to: (a) pull my/our credit report (soft pull; will not affect your score) to review my/our credit file for housing counseling in connection with my pursuit on a loan to purchase real property; (b) pull my/our credit report (soft pull) and review my/our credit file for informational inquiry purposes; and (c) obtain a copy of the HUD-1 Settlement Statement, Appraisal, and Real Estate Note(s) when I/We purchase a home, from the lender who made me/us a loan and/or the title company that closed the loan. I/We understand that any intentional or negligent representation(s) of the information contained on this form may result in civil liability and/or criminal liability under the provisions of Title 18, United States Code, Section 1001.
I authorize the Tillamook Habitat for Humanity Staff to:

(a) pull my/our credit report (soft pull; will not affect your score) to review my/our credit file for housing counseling in connection with my pursuit on a loan to purchase real property;

(b) pull my/our credit report (soft pull) and review my/our credit file for informational inquiry purposes; and

(c) obtain a copy of the HUD-1 Settlement Statement, Appraisal, and Real Estate Note(s) when I/We purchase a home, from the lender who made me/us a loan and/or the title company that closed the loan.

I/We understand that any intentional or negligent representation(s) of the information contained on this form may result in civil liability and/or criminal liability under the provisions of Title 18, United States Code, Section 1001.
- I agree

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Housing Application

Step 1 of 17

Customer

Co-Applicant

Co-Applicant

Customer Employment - Last 2 Years

Co-Applicant Employment - Last 2 Years

Income

Liabilities/Debt

Liquid Funds/Savings/Investments

Living Expenses

Additional Information

Relationship	Age

Previous Employer	Title	Length of Employment	Street/City/State	Phone	Part-time/Full-time

Previous Employer	Title	Length of Employment	Street/City/State	Phone	Part-time/Full-time

CUSTOMER Monthly Amount	CO-APPLICANT Monthly Amount