PARTNERSHIP QUESTIONNAIRE

 

 

Applicant: Please PRINT all answers clearly using an ink pen.  Please mail, fax, or email this completed form to: Highland Rim Habitat for Humanity,  P.O. Box 1295 Tullahoma, TN 37388,  Fax: (931) 393-2383.  Email: habitat1@yahoo.com

Unsigned forms cannot be processed.  A letter will be sent to you within 3-4 weeks with the next steps. If you have any questions about filling out the form, please contact Jim Miller,  Director, at (931) 393-2383 .

DATE: _____/______/____

 

 

Personal Information

Person designated as

head of household/APPLICANT

Adult 18+ living in household or

CO-APPLICANT

Full Name

 

 

Social Security Number

-             -

-              -

Date of Birth

 

 

Legal Marital Status

 

 

Street Address (no P.O. Box)

 

 

City/State/Zip

 

 

How long have you lived at this address?

 

 

Home Phone Number

 

 

Cell Phone Number

 

 

Work Phone Number

 

 

Email:

 

 

 

“I/We hereby consent to Highland Rim Habitat for Humanity to obtain information from credit reporting agencies, employers and others.” Applicant(s) must sign this form granting HRHFH permission to review your credit report. All information obtained in this application is strictly confidential and is not shared with anyone outside of HRHFH.

 

APPLICANT: ___________________________________________________         Date: ______________________________

 

CO-APPLICANT: _______________________________________________  Date: _______________________________

 

 

List everyone who will live in the house with you if selected.

 

Name

 

Date of Birth

 

Gender

 

Age

Full Time Student?

Yes or No

Relationship to Applicant

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant:

  1. Do you work in Coffee or/and Franklin County? yes____ no____.  How long? ________________.
  2. Employer Name_____________________________________ Phone: ________________________.
  3. How much do you earn per hour? ___________. How many hours per week do you work? _________.
  4. What is your gross pay (before taxes) per month? ___________.What is your gross annual salary? __________.
  5. Do you live in Coffee or Franklin County?        yes____ no____.  How long? __________.
  6. Have you ever filed bankruptcy?       yes____ no____.  How long ago? __________.
  7.  

Co-applicant:

  1. Employer Name_________________ Phone: ________________________. How long? ______________.
  2. How much do you earn per hour? ___________. How many hours per week do you work? _________.
  3. What is your gross pay (before taxes) per month? ___________.What is your annual salary? __________.

 

List all MONTHLY amounts of income for each individual in the household:

 

 

Family Member

SSI or DI

Pension

Income

Unemployment

Compensation

Alimony

Income

Child

Support

Is Child Support Court Ordered?

Interest

Invest-ment

Wages,

Tips

Other

TOTAL

1 Applicant

 

 

 

 

 

Yes or No

Circle one

 

 

 

 

2. Co-applicant

 

 

 

 

 

 

 

 

 

 

3. Other-age___

 

 

 

 

 

 

 

 

 

 

4.Other-age___

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total

 

Assets

 

Name of Bank or Credit Union?

Balance

Checking Account

 

 

Savings Account

 

 

Credit Union

 

 

Certificate of Deposit

 

 

Other- IRA or 401k

 

 

Liabilities (Debts)

 

Who do you owe?

Monthly Payment

Balance Owed

Car Loan

 

 

 

Other Loan

 

 

 

Furniture Store/Rent-to-Own

 

 

 

Credit Card

 

 

 

Credit Card

 

 

 

Medical Bills

 

 

 

Child Support

 

 

 

Alimony

 

 

 

Court Ordered Judgments

 

 

 

Amounts in Collection

 

 

 

Any Other Time Payment

 

 

 

Any Other Time Payment

 

 

 

Office Use Only: This section to be completed by Habitat Office.

Total number in household

Household Annual Income $

Number of Adults

Total Monthly Income $

Number of Children

Monthly Debt Payment $

Circle one: 3-bedroom  4-bedroom  5-bedroom

Balance remaining $

 

Current Debt/Income % :

Qualifies as: Very Low (30%-40%)

Monthly Mortgage Payment (est.)

Low (41%- 60%)

Projected Debt/Income Ratio %

 

Credit Report Score:

Meets basic financial guidelines

Yes

 

No

 

Recommend for home visit

Yes

 

No

 

Comment/Suggestion/Referral:

Received:_____/_______/_____ By:___________

Document Sent Date:________________

Scan0001NOTICE:  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 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 Project Act.  The federal agency that administers compliance with this law concerning this credit is the Federal Trade Commission, Washington, D.C.