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APPLICATION FOR HOUSING PRESERVATION ASSISTANCE
| APPLICANT INFORMATION |
| APPLICANT: __________________________________
SS# ______________ |
| CO-APPLICANT: _______________________________
SS# ______________ |
| STREET ADDRESS: ___________________________
PHONE# ___________ |
| CITY: ____________________________
STATE: _________ ZIP: ___________ |
| MAILING ADDRESS (IF DIFFERENT FROM ABOVE): _____________________ |
| CITY: ____________________________
STATE: _________ ZIP: ___________ |
| HOUSEHOLD MEMBER INFORMATION |
| HOUSEHOLD MEMBER |
RELATIONSHIP |
DATE OF BIRTH |
SOCIAL SECURITY # |
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ANTICIPATED ANNUAL INCOME INFORMATION
MUST INCLUDE ANNUAL INCOME FOR ALL HOUSEHOLD MEMBERS |
| HOUSEHOLD MEMBER |
WAGES/ SALARIES |
SOCIAL SECURITY |
SSI |
BENEFIT/ PENSION |
CHILD SUPPORT |
OTHER INCOME |
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| TOTALS: |
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TOTAL ANNUAL INCOME __________________________
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NAME, ADDRESS & TELEPHONE NUMBER OF NEAREST RELATIVE NOT LIVING WITH YOU
NAME: ______________________________________ TELEPHONE# ____________________
ADDRESS: ____________________________________________________________
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| INFORMATION FOR GOVERNMENT PURPOSES |
| I/We certify that the information provided in this application is true and correct as of
the date set forth opposite my/our signature(s) on this application and acknowledge my/our
understanding that any intentional or negligent misrepresentation(s) of the information contained
in this application may result in civil liability and/or criminal penalties including, but not
limited to, fine or imprisonment or both under the provisions of Title 18, United States Code,
Section 1001, Et Seq. And liability for monetary damages to the lender, its agents, successors,
and assigns, insurers and any other person who may suffer any loss due to reliance upon any
misrepresentation which I/we have made on this application. |
| _____________________________________ |
________________ |
| APPLICANT'S SIGNATURE |
DATE |
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| _____________________________________ |
________________ |
| CO-APPLICANT'S SIGNATURE |
DATE |
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| INFORMATION FOR GOVERNMENT PURPOSES |
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The following information is requested by the Federal Government for certain types of loans
related to a dwelling, in order to monitor the lender's compliance with equal credit opportunity,
fair housing and home mortgage disclosure 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. 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 above information, 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 low for the
particular type of loan applied for.)
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