AFFORDABLE HOUSING ASSISTANCE PLAN APPLICATION
____ Purchasing

____ New Construction

____ Repairs


APPLICANT I. APPLICANT INFORMATION CO-APPLICANT

Applicant's Name (include Jr. or Sr. if applicable)

 Co-Applicant's Name (include Jr. or Sr. if applicable)
Social Security No.

 Home Phone (include area code)

 Age

 Social Security No.

 Home Phone (include area code)

 Age
Married Unmarried (inlude single, divorced, widowed)

Dependents Living in Household (not listed by Co-Applicant)

No. _____ Ages ____ , ____ , ____ , ____ , ____ 		Married Unmarried (inlude single, divorced, widowed)

Dependents Living in Household (not listed by Applicant)

No. _____ Ages ____ , ____ , ____ , ____ , ____
Present Mailing Address (Street Or P.O.Box, City, State, Zip Code)




Present Mailing Address (Street Or P.O.Box, City, State, Zip Code)




Own Rent _____ No. Yrs. Own Rent _____ No. Yrs.
Name, Address & Telephone Number of Nearest Relative Not Living With You Name, Address & Telephone Number of Nearest Relative Not Living With You
Name ______________________________
Address ____________________________
Telephone No _____________________
 Name ______________________________
Address ____________________________
Telephone No _____________________


APPLICANT II. EMPLOYMENT INFORMATION CO-APPLICANT

Name & Address of Employer


 Self-Employed
Name & Address of Employer


 Self-Employed
Yrs. on this job ____
Yrs. employed in this line of work/profession ____ 		Yrs. on this job ____
Yrs. employed in this line of work/profession ____
Position/Title/Type of Business

 Business Phone (include area code)

 Position/Title/Type of Business

 Business Phone (include area code)


III. FAMILY INCOME (BEFORE TAXES)

Salaries

$____		 Social Security

$____		 SSI

$____		 Retirement

$____		 AFDC

$____		 Welfare

$____		 Other

$____		 TOTAL MONTHLY INCOME

$________________
Down Payment and Closing Cost Rehab/Repairs (please be specific about repairs/directions to your home)


IV. WHAT IS YOUR NEED FOR ASSISTANCE?

List Repairs ________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Directions to your home (for REPAIRS ONLY) ______________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________


V. CERTIFICATION

Certification: 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


 Co-Applicant's Signature


 Date


VI. INFORMATION FOR GOVERNMENT PURPOSES

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 law for the particular type of loan applied for.)

APPLICANT: I do not wish to furnish this information. CO-APPLICANT: I do not wish to furnish this information.
   
Race/National
Origin 		American Indian or Alaskan Native
Black, not of Hispanic origin
Asian or Pacific Islander
White, not of Hispanic origin
Hispanic
Other (specify) ______________
 Race/National
Origin 		American Indian or Alaskan Native
Black, not of Hispanic origin
Asian or Pacific Islander
White, not of Hispanic origin
Hispanic
Other (specify) ______________
   
Sex: Female Male Sex: Female Male

Interviewer's Signature


 Interviewer's Phone Number (include area code)


 Date

FOR OFFICE USE ONLY
Other Assistance Programs Applied/Eligible For:


____ WAP ____ Home ____ Other _________
Date      /    / Mailed Picked Up
Who Referred You?
Have You Seen A Lender? Yes No
(Rev. 11/99)