Homesteader Application

 
               Date:      

     Your Name:    

Street Address:       City:      

               State:                                        Zip Code:      

Reason for Housing Need:  


Number of bedroms needed:    

Are there any special considerations we would need to make for your home?



HOUSEHOLD INFORMATION:
Please complete the fields below, starting with yourself, listing all other persons who will live with you in the home.

Name:       Date of Birth:           SSN:    

   Sex:   Select a sex... Male Female                                               Relation to head of household:    


Name:     Date of Birth:       SSN:  

   Sex:   Select a sex... Male Female                                            Relation to head of household:  


Name:     Date of Birth:       SSN:  

   Sex:   Select a sex... Male Female                                             Relation to head of household:  


Name:     Date of Birth:       SSN:  

   Sex:   Select a sex... Male Female                                             Relation to head of household:  


Name:     Date of Birth:      SSN:  

   Sex:   Select a sex... Male Female                                             Relation to head of household:  


Name:     Date of Birth:      SSN:  

   Sex:   Select a sex... Male Female                                            Relation to head of household:  


PERSONAL REFERENCES:

   Name:          Phone Number:          

Address:       City:    

     State:                                        Zip Code:      


   Name:        Phone Number:      

Address:     City:  

     State:                                    Zip Code:    


   Name:        Phone Number:      

Address:     City:  

     State:                                    Zip Code:    


COMPLETE HOUSING HISTORY:

Present Landlord:                                       Phone Number:                    

             Address:                                       City:          

                  State:         Zip Code:                      Length of time:             
                 
     Monthly Rent:                                                              Monthly gas & electric costs:      


Previous Landlord:                                     Phone Number:                

              Address:                                     City:        

                   State:       Zip Code:                     Length of time:          
                  
      Monthly Rent:                                                            Monthly gas & electric costs:    


Previous Landlord:                                     Phone Number:                

              Address:                                     City:        

                   State:       Zip Code:                      Length of time:      
                      
      Monthly Rent:                                                            Monthly gas & electric costs:    


Previous Landlord:                                     Phone Number:                

              Address:                                     City:        

                   State:       Zip Code:                 Length of time:         
                   
      Monthly Rent:                                                            Monthly gas & electric costs:    


WORK HISTORY/INCOME:

                  Employer:       Position:    

                    Address:             City:          

                         State:                       Zip Code:      

Dates of Employment:          to      

      Salary Per Week:      


                  Employer:     Position:  

                    Address:           City:        

                         State:                     Zip Code:    

Dates of Employment:        to    

      Salary Per Week:    


                  Employer:     Position:  

                    Address:           City:        

                         State:                     Zip Code:    

Dates of Employment:        to        

      Salary Per Week:    


OTHER INCOME:

         V/A:                         SSI:             SSD:      

         FIA:                        Rent:         Pension:      

Law Suits:          Child Support:          Stocks:      

     Bonds:        Home Business:          


DECLARATIONS:

Do you have any other outstanding debts other than what is listed under expenditures? (If none type 'No')  


Do you have any other outstanding loans, personal or other? (If none type 'No')  


Are you a co-maker or endorser on any other loans? (If none type 'No')  


Do you have any past obligations owed to or insured by an agency of the government? (If none type 'No')  


Are there any unsatisfied judgments against you? (If none type 'No')  


Have you declared bankruptcy in the past seven years or do you have bankruptcy pending? (If none type 'No')  



EXPENDITURES::

                              Monthly Cost                         Past Balance


              Rent:                                        
 
               Gas:                                        

          Electric:                                        

            Water:                                        

             Cable:                                        

            Phone:                                        

         Garbage:                                        

              Food:                                        

      Eating Out:                                        

Transportation:                                        
(includes payments,
gas, maintenance)

  Medical Bills:                                        

Child Support:                                        

         Alimony:                                        

  Credit Cards:                                        
                                                             
                                                             
                                                             

        Clothing:                                        

Entertainment:                                        

              Gifts:                                        

           Giving:                                        

             Total:                                     



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