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Do you own a:
Yes
No
Do you own a:
Stove
Car (#1)
Refrigerator
Make and Year
Washer
Car (#2)
Dryer
Make and Year
Yes
No
10. DEBT
To W h o m D o Yo u a n d t h e C o - a p p l i c a n t O w e M o n e y?
Car
Monthly
Payment
$
Unpaid
Balance
Name and Address of Company
Monthly
Payment
$
$
Mos. left to pay:
Furniture
Monthly
Payment
$
Unpaid
Balance
Name and Address of Company
Monthly
Payment
$
Monthly
Payment
$
$
Unpaid
Balance
$
Monthly
Payment
$
Unpaid
Balance
$
Mos. left to pay:
Column 1: Subtotal of Payments
$
Unpaid
Balance
$
Mos. left to pay:
Mos. left to pay:
Medical
$
Mos. left to pay:
Mos. left to pay:
Credit Card
Unpaid
Balance
/month
Alimony/Child Support
$
/month
Job-related Expenses
$
/month
(Child Care, Union Dues, etc.)
$
/month
Column 2: Subtotal of Payments
$
/month
Column 1: Subtotal of Payments
$
/month
Total Monthly Expenses
$
/month
1 1 . D E C L A R AT I O N S
Ple a s e C h e c k t h e B o x T h a t B e s t A n s w e r s t h e F o l l o w i n g Q u e s t i o n s f o r Yo u a n d t h e C o - a p p l i c a n t.
Applicant
Co-applicant
a.
Do you have any debt because of a court decision against you?
Yes
No
Yes
No
b.
Have you been declared bankrupt within the past 7 years?
Yes
No
Yes
No
c.
Have you had property foreclosed on in the past 7 years?
Yes
No
Yes
No
d.
Are you currently involved in a lawsuit?
Yes
No
Yes
No
e.
Are you paying alimony or child support?
Yes
No
Yes
No
f.
Are you a U.S. citizen or permanent resident?
Yes
No
Yes
No
Answering “yes” to these questions does not automatically disqualify you. If you answered “yes” to any question a through e, however, please
explain on a separate sheet of paper.
1 2 . A U T H O R I Z AT I O N A N D R E L E A S E
I understand that by filing this application, I am authorizing Habitat for Humanity to evaluate my actual need for a Habitat home, my ability to repay
the no-interest loan and other expenses of homeownership and my willingness to be a partner family. I understand that the evaluation will include
personal visits, a credit check, and employment verification. I have answered all the questions on this application truthfully. I understand that if I
have not answered the questions truthfully, my application may be denied, and that even if I have already been selected to receive a Habitat home,
I may be disqualified from the program. The original or a copy of this application will be retained by Habitat for Humanity even if the application is
not approved.
I understand that Habitat for Humanity screens all potential staff (whether paid or unpaid), board members, and applicant families on the sex offender
registry. By completing this application, I am submitting to such an inquiry.
Applicant Signature
X
Date
Co-applicant Signature
Date
X
PLEASE NOTE: If more space is needed to complete any part of this application, please use a separate sheet of paper and attach it to this
application. Please mark your additional comments with “A” for Applicant or “C” for Co-applicant.
3012/25M/CAER/2-06
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