Evergreen Habitat for Humanity

PROGRAM ELIGIBILITY ASSESSMENT FOR HOUSING

DEAR PROGRAM ELIGIBILITY ASSESSMENT APPLICANT: To determine if you are eligible for the Habitat for Humanity
homeownership program please fill out this Program Eligibility Assessment application as completely and accurately as
possible. All information you include on this application will be kept confidential.
1. PROGRAM ELIGIBILITY ASSESSMENT APPLICANT INFORMATION
APPLICANT CO-APPLICANT
Applicant’s Name: Co-Applicant’s Name:

Social Security Number: Date of Birth: Social Security Number: Date of Birth:

Day Phone #: Evening Phone #: Day Phone #: Evening Phone #:

Email Address (if applicable): Email Address (if applicable):

Current Address:

City State Zip Code

Mailing Address (if different from above):

City State Zip Code

Status Status
U.S. Citizen  Yes  No U.S. Citizen  Yes  No
Permanent Resident  Yes  No Permanent Resident  Yes  No
Temporary Resident  Yes  No Temporary Resident  Yes  No
Married (incl. Common Law)  Yes  No Married (incl. Common Law)  Yes  No
Date: Date:
Divorced  Yes  No Divorced  Yes  No
Separated  Yes  No Separated  Yes  No
Other (single, widowed, etc.)  Yes  No Other (single, widowed, etc.)  Yes  No
What is your primary (first) language? Are you able to speak/read English?  Yes  No
If no, please provide the name and phone number of a friend or relative who can translate for you.
Translator Name: Translator Phone Number:

*Qualification information
Citizenship: In order to meet qualifications, applicant(s) must be a permanent resident or must have already
applied for residency.
Other Household Members (people who currently live with you and will live in the Habitat house with you if approved)
Employed Name Relationship Age Male or Income
(Yes/No) Female
1.
2.
3.
4.
5.
6.
7.
You MUST provide documentation for all household members who earn an income. Attach to application.
Have you applied for the Habitat homeownership program before?  Yes  No
If yes, when and with which Habitat affiliate?
We are pledged to the letter and spirit of U.S. policy for the achievement of equal housing opportunity throughout the nation. We encourage and
support an affirmative advertising and marketing program in which there are no barriers to obtaining housing because of race, color, religion, sex,
handicap, familial status, sexual orientation, age, gender identity or national origin.
 2. PRESENT HOUSING
Do you  Rent or  Own?
How long at current address? ______Years _____Months
RENT INFORMATION
What is your monthly rent payment? $____________
If living at present address for less than two years complete the following:
Last Address:

SUBSIDIZED HOUSING INFORMATION

Do you currently live in subsidized housing?  Yes  No Amount Housing Agency Pays _________
If yes, please answer the following questions. If no, please continue to the next section.
Public Housing Agency:_______________________________ Portion of Rent You Pay __________
Phone Number: ___________________ Fax Number: ___________________

3. EMPLOYMENT HISTORY
APPLICANT CO-APPLICANT
CURRENT EMPLOYER #1 CURRENT EMPLOYER #1
Name & Address of CURRENT Employer: Name & Address of CURRENT Employer:

From: (month/year): __________ To:_________ From: (month/year): __________ To:__________

Monthly Gross Wage: $________ Monthly Gross Wage: $________
Job Description: Job Description:

Type of Business: Type of Business:

Supervisor Name: Phone #: Supervisor Name: Phone #:

*Qualification Information: In order to meet qualifications, applicant(s) must have at least one continuous year of
employment history in the same industry.
CURRENT EMPLOYER #2 (if applicable) CURRENT EMPLOYER #2 (if applicable)
Name & Address of CURRENT Employer: Name & Address of CURRENT Employer:

Hire Date (mo/day/yr): __________ Hire Date (mo/day/yr): __________

Monthly Gross Wage: $________ Monthly Gross Wage: $________
Job Description: Job Description:

Type of Business: Type of Business:

Supervisor Name: Phone #: Supervisor Name: Phone #:

Please explain any gaps in employment history here (If needed attach page of additional information).
 4. MONTHLY INCOME
GROSS MONTHLY INCOME APPLICANT CO-APPLICANT ADULTS IN HOUSEHOLD*
Gross Employment $ $ $
Income (gross is before
deductions)
AFDC/TANF (Cash
Assistance)
AFDC/TANF Start Date:
Disability
Social Security
SSI
Alimony
Child Support
Other (explain)
Other (explain)
TOTAL $ $ $
If any of the ADULTS in the household who earn an income are students, please complete the following:
NAME AMT OF INCOME AMOUNT OF INCOME
GIVEN TO HOUSEHOLD GIVEN TO SCHOOL EXPENSES
$ $
$ $
$ $

5. MONTHLY EXPENSES & LIABILITIES

LIABILITIES (Debts you owe)
List and attach any additional liabilities on a separate sheet of paper.
Original Balance Current Balance Monthly Payments
Auto Loan: $__________ $__________ $__________
Credit Card: $__________ $__________ $__________
Credit Card: $__________ $__________ $__________
Student Loan: $__________ $__________ $__________
Other (______): $__________ $__________ $__________
Other (______): $__________ $__________ $__________
Child Support: $__________
Alimony Pmt: $__________
Utilities
Natural Gas: $__________ Cell Phone: $____________
Water: $__________ Car Insurance: $__________
Garbage: $__________ Cable: $_________________
Electricity: $__________ Other: $_________________
Total Liabilities: $_______________
6. DECLARATIONS
Please check the box that best answers the following questions for you and the co-applicant.
Applicant Co-Applicant
1. Do you have any debt because of a court decision against you?  Yes  No  Yes  No
2. Have you been declared bankrupt within the past 7 years?  Yes  No  Yes  No
3. Have you ever had property foreclosed within the past 7 years?  Yes  No  Yes  No
4. Have your wages or bank accounts been garnished in the last 7  Yes  No  Yes  No
years?
5. Are you currently involved in a lawsuit?  Yes  No  Yes  No
6. Have you owned a home in the past three years?  Yes  No  Yes  No
*Answering “yes” to any of the above questions does not automatically disqualify you. However, if you answered
“yes” please explain on an attached piece of paper.
 7. ASSETS
Do you own land or any other real property?  Yes  No (If yes, please describe including location)

Is there a mortgage on the land?  Yes  No If yes: Monthly payment $ Unpaid Balance $
Do you own a car?  Yes  No
Car #1) Make and Year Car #2) Make and Year
Do you own any additional assets (for example: additional vehicles, jewelry, stocks, bonds, money market funds,
etc.)  Yes  No If yes, please describe:
8. WILLINGNESS TO PARTNER
To be considered for a Habitat home, you and your family must be willing to complete 500 “sweat equity” hours.
Your help in building your home and the homes of others is called “sweat equity” and may include clearing the lot,
helping with construction, working in the Evergreen Habitat office, education classes, or other approved activities.
APPLICANT CO-APPLICANT
I am willing to complete the required sweat equity hours.  Yes  No  Yes  No
My family and I will use home as principal residence.  Yes  No  Yes  No

9. AUTHORIZATION AND RELEASE

I understand that by filing this Program Eligibility Assessment 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 Program Eligibility Assessment application truthfully. I understand that if I have not answered the
questions truthfully, my Program Eligibility Assessment 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. I also understand that this is a non-mandatory, nonbinding Program
Eligibility Assessment application and does not guarantee qualification. The original or a copy of this Program Eligibility Assessment
application will be retained by Habitat for Humanity even if the it is not approved.
X______________________________________________________ X___________________________________________________________
Applicant Signature Date Co-Applicant Signature Date

10. INFORMATION FOR GOVERNMENT MONITORING PURPOSES

Please Read This Statement Before Completing the Box Below: The following information is requested by the federal government for
loans related to the purchase of homes in order to monitor the lender’s compliance with equal credit opportunity and fair housing laws. You
are not required to furnish this information, but are encouraged to do so. The law provides that a lender may neither discriminate on the basis
of this information, nor on whether you choose to furnish it or not. However, if you choose not to furnish it, under federal regulations this
lender is required to note race and sex on the basis of visual observation or surname. If you do not wish to furnish the information below,
please check the box below. (Lender must review the above material to assure that the disclosures satisfy all requirements to which the
lender is subject under applicable state law for the loan applied for.)
APPLICANT CO-APPLICANT
 I do not wish to furnish this information  I do not wish to furnish this information
Race/National Origin Race/National Origin
 American Indian or Alaskan Native  American Indian or Alaskan Native
 Native Hawaiian or other Pacific Islander  Native Hawaiian or other Pacific Islander
 Black/African American  Black/African American
 Caucasian  Caucasian
 Asian  Asian
 American Indian or Alaskan Native AND  American Indian or Alaskan Native AND
Caucasian Caucasian
 Asian AND Caucasian  Asian AND Caucasian
 Black/African American AND Caucasian  Black/African American AND Caucasian
 American Indian or Alaskan Native AND  American Indian or Alaskan Native AND
Black/African American Black/African American
 Other (specify)  Other (specify)
Ethnicity Ethnicity
 Hispanic  Non-Hispanic  Hispanic  Non-Hispanic
Sex Sex
 Female  Male  Female  Male
Birth date: / / Birth date: / /
Marital Status Marital Status
 Married  Married
 Separated  Separated
 Unmarried (incl. single, divorced, widowed)  Unmarried (incl. single, divorced, widowed)
Disabled Disabled
 Yes  No  Yes  No