Submit the following items
with your application for
SUSLA AFI Application Packet
homeownership or
education:
Homeownership & Education IDA’s
Copy of 2 most
recent pay stubs
(within last 60
days)
APPLICANT NAME / RESIDENCE
Copy of previous
Name: ............................................................................................................................................
3 yrs tax returns
(Homeownership)
Copy of prior year
tax return
(Education)
Last Name
First Name
Middle Initial
Suffix
Address: ........................................................................................................................................
Street Address
Apartment/Unit #
.......................................................................................................................................
City
State
Zip Code
Copy of Valid
Home Phone: (........)............................
Drivers License or
State Issued ID
Primary Email: .............................................................................................................................
Copy of 2nd form of
Social Security Number: ..................................
Alternate Phone: (........)...........................
Head of Household:  Yes
 No
ID (SS Card,
Passport, Birth
Certificate)
Copy of 1099’s if
self-employed
Proof of any
Student Name: ................................................................................
High School: ...................................................... GPA: ....................
MAILING ADDRESS (IF DIFFERENT FROM ABOVE)
supplemental
income (child
support, SSI, etc.)
Name: ............................................................................................................................................
Copy of credit
Address: ........................................................................................................................................
report with scores
(Homeownership)
Last Name
students: recent
report card with
overall G.P.A.
Middle Initial
Street Address
Suffix
Apartment/Unit #
.......................................................................................................................................
City
High school
First Name
State
Zip Code
CURRENT EMPLOYER
Name: ..............................................................................Phone:...........................................
Address: .................................................................................................................................
Length of Time Employed: .................................................................
2ND EMPLOYER (IF APPLICABLE)
Name: ..............................................................................Phone:...........................................
Address: .................................................................................................................................
Length of Time Employed: .................................................................
FRIEND/RELATIVE CONTACT INFORMATION
Please enter contact information for one person who does not live with you, and would
be able to contact you, in the event that you move.
CONTACT PERSON:
Name: ............................................................................................................................................
Last Name
First Name
Middle Initial
Suffix
Address: ........................................................................................................................................
Street Address
Apartment/Unit #
.......................................................................................................................................
City
State
Home Phone: (........)............................
₂
Zip Code
Alternate Phone: (........)...........................
DEMOGRAPHIC INFORMATION
Gender:  Male
 Female
Race/Ethnicity:
 African American
 Caucasian
 Native American
Marital Status:
 Single, Never Married  Married
 Divorced
 Widowed
 Other: ..................................................
Employment Status:
If you are both a student
and employed, please
select the Full-time or Parttime employed option.
 Full-time employed
 Unemployed
 Student
 Asian American/Pacific Islander
 Hispanic
 Other: .................................................
 Separated
 Part-time employed
 Retired
 Other: ...........................................
Date of Birth: ......../......../.............
MM / DD / YYYY
Highest Level of Education:
 Completed Grades K-5
 Completed Grades 6-8
 Completed Grades 9-11
 High School Diploma/General Education Development (GED)
 Vocational School Diploma/Degree
 Some College
 AA Degree/Graduated Two-year College
 BA/BS Degree/Graduated Four-year College
 Some Graduate School/Attended Graduate School
 MA/MS/Graduate Degree(s)
Residence Location at Time of Application:
 Major Urban Area (population greater than 1,000,000)
 Minor Urban Area (population less than 1,000,000)
 Rural Area
 Remote Area
 Unknown
Asset Goal (Anticipated Asset Type):
 First Home Purchase  Education  Transfer IDA to dependant (education)
₃
FINANCIAL INFORMATION
Has the applicant ever used a direct deposit procedure for depositing his/her
paychecks into a bank account?
 Yes
 No
TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF), FEDERAL EARNED INCOME TAX CREDIT
(EITC), & STATE EITC ELIGIBILITY
TANF
Federal EITC
State EITC
► Household refers to all
individuals who share
use of a dwelling unit as
primary quarters for
living and eating,
separate from other
individuals.
► Adults refer to
individuals age 18 or
older, including the
applicant, living in the
household.
► Children refer to
individuals under the
age of 18 living in the
household.
► Adjusted Gross
Annual Income is a
person's income (e.g.,
wages, salaries, tips,
dividends, business
income) less deductions
and expenses allowed
by the IRS (e.g., student
loan deductions,
moving expenses, selfemployment tax). It is
also the amount shown
on the following IRS
forms: line 4 of IRS
Form 1040EZ, line 22 of
Form 1040A, or line 35
of Form 1040.
Currently Eligible?
 Yes
 No
 Yes
 No
 Yes
 No
Currently Receiving?
 Yes
 No
 Yes
 No
 Yes
 No
Has Ever Received?
 Yes
 No
 Yes
 No
 Yes
 No
HOUSEHOLD INFORMATION
Number of Adults: .......................................................................................................................
Number of Children: ....................................................................................................................
Total Number of Persons in Household: ..................................................................................
INCOME
Gross (or Adjusted Gross) Annual Income Amount: ............................................................
As of Date: ....................................
Documentation Method:
 Pay Stub
 W-2-wages
 1099-wages
 Other: ..................................................
OTHER INCOME
Type of Income
Alimony Payment
Yes/No
 Yes
 No
Child Support
 Yes
 No
Supplemental Security Income (SSI)/
Social Security Disability (SSDI)
Supplemental Nutrition Assistance
Program (SNAP)/Food Stamps
 Yes
 No
 Yes
 No
₄
Annual Amount
FINANCIAL INFORMATION (CONTINUED)
ASSETS
Asset Type
Own principal residence
Yes/No
 Yes
Value
 No
Own other homes
 Yes
 No
Business ownership
 Yes
 No
Investments (e.g., cash out
 Yes
 No
Checking Account
 Yes
 No
Savings Account
 Yes
 No
Vehicles
 Yes
 No
Balance Due
value of 401(k), IRA, stocks, or
other investment as of date of
applicant enrollment)
Fill out the following information if you own a vehicle(s):
Vehicle No.
Vehicle 1 (primary)
Value
Balance Due
Make
Model
Vehicle 2
Vehicle 3
LIABILITIES
Liability
Outstanding Bills Past Due
(excluding those listed below)
Student loan outstanding balances
Yes/No
 Yes
 No
 Yes
 No
Medical bills outstanding balances
 Yes
 No
Personal loan outstanding balances
 Yes
 No
Credit card outstanding balances
 Yes
 No
Payday loans
 Yes
 No
All other liabilities
 Yes
 No
₅
Value
Mileage
Use this section only if
you have other adults
residing in your
household. If you do
not, proceed to
Authorization &
Signature Section.
OTHER HOUSEHOLD MEMBER FINANCIAL INFORMATION (CO-APPLICANT)
In this section, enter financial information for each adult member of the applicant’s
household. Please duplicate this section for each adult member of the applicant’s
household.
Household Member’s Name: .............................................................................
Relationship to Applicant:  Husband
 Wife
 Mother
 Cousin
 Child
 Brother
 Unknown
 Father
 Sister
 Other.................................................................
OTHER HOUSEHOLD MEMBER’S INCOME (CO-APPLICANT)
Gross (or Adjusted Gross) Annual Income Amount: $..........................................................
As of Date: ....................................
Documentation Method:
 Pay Stub
 1099-wages
 W-2-wages
 Other: ..................................................
OTHER HOUSEHOLD MEMBER’S ASSETS (CO-APPLICANT)
Asset Type
Own principal residence
Yes/No
 Yes
 No
Value
$
Balance Due
$
Own other homes
 Yes
 No
$
$
Business ownership
 Yes
 No
$
$
Investments (e.g., cash out
 Yes
 No
$
$
Checking Account
 Yes
 No
$
Savings Account
 Yes
 No
$
Vehicles
 Yes
 No
$
value of 401(k), IRA, stocks, or
other investment as of date of
applicant enrollment)
$
Fill out the following information if the household member owns a vehicle(s). Exclude
vehicles previously included by the applicant.
Vehicle No.
Vehicle 1
Value
Balance Due
Vehicle 2
Vehicle 3
6
Make
Model
Mileage
OTHER HOUSEHOLD MEMBER’S LIABILITIES (CO-APPLICANT)
Liability
Outstanding Bills Past Due
(excluding those listed below)
Student loan outstanding balances
Yes/No
 Yes
Value
 No
 Yes
 No
Medical bills outstanding balances
 Yes
 No
Personal loan outstanding balances
 Yes
 No
Credit card outstanding balances
 Yes
 No
Payday loans
 Yes
 No
All other liabilities
 Yes
 No
SIGNATURE
I /We hereby acknowledge that the information listed above is accurate and true.
I/We have not provided false information or documentation regarding household
earned income, supplemental income, or assets.
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 provision of Title 18, United States Code, Section 1001.
______________________________
________________
Applicant
Date
________________________________
_________________
Co-Applicant
Date
RETURN APPLICATION TO SUSLA INTAKE CENTER:
610 TEXAS STREET, SUITE 104, SHREVEPORT, LA 71101
CONTACT BRIDGET POWELL, PROGRAM COORDINATOR AT
318-670-9688 FOR ADDITIONAL INFORMATION
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