| Pre-Screen Questionnaire |
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| All information must be provided or the pre screen application will not be processed. A response can be expected within 30 days upon receipt of your pre screen request. For additional information, please see the homeownership page. |
| Applicant #1 |
| First Name | |
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| Last Name | |
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| Co-Applicant |
| First Name | |
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| Last Name | |
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| Number of people currently living in this home (including yourself) |
| Adults (anyone 18 or older) | |
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| Children | |
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| Current Address/Residence |
| Address | |
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| Lenght of Time at Current Address | |
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| If less than 12 months, List Previous Address | |
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| Length of Time at Previous Address (please indicate years or months) | |
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| Email Address | |
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| Daytime Phone | |
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| Other Phone | |
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| Please check all that apply to your current housing problem. |
| Cost-burdened (cost of rent plus utilities, excluding phone, is greater than 35% of family’s monthly income) |
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| Overcrowding (determined by number of persons, their ages and gender) |
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| Substandard Conditions (e.g. structural problems, problems with plumbing, sewage or electrical systems, etc.) |
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| Unsuitable Neighborhood (unsafe or unsanitary) |
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| Homelessness (living with friends or relatives or in temporary housing) |
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| Living in government subsidized housing or have been denied conventional or government assisted financing |
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| Employment Information for Applicant |
| Is Applicant Currently Employed? | |
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| If Currently Employed, Fill out the Following: |
| Name of Current Employer | |
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| Location | |
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| Length of Current Employment | |
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| Hourly Wage | |
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| Average number of hours per week | |
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| Employment Information for Co-Applicant |
| Is Co-Applicant Currently Employed? | |
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| If Currenlty Employed, Fill out the Following: |
| Name of Current Employer | |
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| Location | |
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| Length of Current Employment | |
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| Hourly Wage | |
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| Average number of hours per week | |
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| Please list all other sources of earnings and income per month. (rounded in dollars, no cents. Put a zero if you don't receive any)
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| Child Support | |
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| Section 8/Rental Assistance | |
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| Disability | |
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| Social Security | |
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| Other | |
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Circumstances that can STOP you from becoming a Habitat for Humanity Homeowner include the following.
(Please reapply in the future if any of the following issues change or are resolved.)
• Lack of financial resources to support home ownership
• Current bankruptcy or bankruptcy that has not been discharged for at least 2 years.
• Outstanding foreclosures or repossessions.
• Outstanding judgments. (A judgment is a court ordered collection.)
• Current homeowner—must not have owned a home within the last year.
• Yearly income does not fall within the guidelines according to family size |
| I have read the basic qualifications information listed here and the information I have provided is true to the best of my knowledge. |
| Full Name | |
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| Please enter the letters that appear in this image |
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