The ECDC EDG Individual Development Accounts (IDA) Program by 49ph3B28


									                 The ECDC EDG Individual Development Accounts (IDA) Program
                                 Candidate Application Form
Please note that all information requested on this application form will be kept confidential within the
ECDC EDG Individual Development Accounts (IDA) Program. The personal and financial information
collected on this form is necessary only for program evaluation purposes and to establish a custodial
account. If you have an outstanding federal tax lien, owe past due child support, or have a collection
account with one of our partner banks, you must resolve the debt prior to submitting an IDA application.
The ECDC EDG staff member will complete applications in collaboration with the Applicant. The
completed application will be reviewed within one week of receipt. If approved, the applicant’s information
will be sent to the bank to establish their IDA custodial account. Please print.
A. Personal Information
1. First Name: ____________________________ Last Name: __________________________
2. Social Sec. No.: _____ - ____ - _______
3. Street: ___________________________________________________ Apt #:                          ________
4. City: _____________________________________                   State: ____       Zip Code: ________
5. Home Phone: (____)_________ Work Phone: (____)_________ Cell: (____)_____________
6. E-mail address: _____________________________________________________________
7. Are you a refugee or asylee?         Yes          No
   If No, what is your legal status: ________________________,

8. Gender:      Female          Male
9. Date of Birth: Month: ______________ Day: _____________ Year: _________________
10. Ethnicity:   African American                         Caucasian
                 Latino or Hispanic                       Asian, Pacific Islander
                 Native American                          Other (please specify )________________
11. What is your country of origin?
   Afghanistan                            Cuba                                 Laos
   Albania                                Eritrea                              Liberia
   Angola                                 Ethiopia                             D. R. Congo
   Bosnia                                 Former Soviet Union                  Sierra Leone
   Burma                                  Gambia                               Somalia
   Burundi                                Haiti                                South Africa
   Cambodia                               Indonesia                            Tibet
   Chad                                   Iran                                 Uganda
                                          Iraq                                  Vietnam
                                                                               Other (specify)______

                                                                                   EDG IDA Application p.1
11. Highest Level of Education Completed:
              Grade K through 5
              High School Diploma or GED
              Attended some college
              Graduated college

12. Applicant’s marital status:      Single (never married)        Married
                                     Separated                     Divorced              Widowed
13. Place of Residence
              Major urban area (population greater than one million)
              Minor urban area or suburban (population less than one million)
              Small town or rural area

14. Will you save as an individual or family?             Individual            Family

15. Over what time period (minimum 6 months) will you save?            __________months/years

B. Applicant’s Goals
1. How did you hear about the IDA program? _______________________________________
2. Indicate one desired asset for your savings goal:

   Home purchase - Must be a first-time homebuyer or has not owned a home in the last three


   Education – self

   Education – spouse or child

        *Note: Applicants desiring to save towards the purchase of an automobile must show a
        documented necessity for the purpose of transportation for post-secondary education,
        vocational training, or recertification.

3. Describe in detail how you plan to use your IDA funds (what will be purchased using the

4. Indicate which banking institution you would like to use to make your IDA deposits.
   CitiBank (must complete Form W-9 for Citibank)

5. You must complete a budget and submit it along with this application. Within your budget,
you must show a monthly allocation of a certain amount you want to save for your IDA account.
ECDC EDG has a template for you to use. How much money is needed to reach your asset
goal? $______________

 INVEST in Your Future with ECDC EDG IDA                                                        2
  6. Do you know about the Earned Income Tax Credit (EITC)?                                  Yes       No

  7. Have you ever received an EITC refund?                                                  Yes       No

  8. Are you planning to use your EITC refund as part of your IDA savings?
                                                                                             Yes      No

  D. Household Income Information

  Household members:

  1. Number of adults (including yourself) 18 or older in the household:_____

  2. Number of children under the age of 18 in the household:____________

  3. Complete the following information for every member of your household.
                                               If under 18, what is
                                                  the applicant’s                   Full- time      Total     Annual
Name of household         Date of Birth         relationship to the       Hourly     or part-      monthly   Household
   member:                                         child (Parent,          rate:      time:        income:    Income
                                              guardian, dependent)

Example: Jane               1-10-98                Dependent              $9.75        FT          $1,560
Example: Jose               3-25-93                Dependent                  n/a      n/a          $200

  6. What is the primary language spoken in your household? ________________________
  * Note: Income information should be consistent with pay stubs submitted.

  E. Assets and Liabilities

  Note: Applicants cannot have more than $10,000 in savings or business assets exclude
  1 home and 1 vehicle.
  1. Assets and Liabilities:                  (Circle one)
      a. Do you own a vehicle(s)?              Yes     No  Value of vehicle(s): $____________________
                                                           Outstanding vehicle loan(s): $_____________
                                                  As of what date:________________________
      b. Net asset value

      c. Do you have a                 Yes             No     Amount in account: $____________________
      checking account?
      d. Do you have a savings         Yes             No     Amount in account: $___________________
      e. Do you have Health Insurance Yes              No
      f. Do you have outstanding loans?: Yes           No     Amount owed: ______________

    INVEST in Your Future with ECDC EDG IDA                                                                    3
2. Budget: You must attach a copy of your budget to your application. Be sure to include your
monthly IDA savings amount within your calculations. Your intermediary can provide you with a
budget template. Your application will not be accepted without a copy of your budget.

F. Emergency Contact Information

Please list one relative or friends who would definitely know how to contact you, even if you move:
   1. Name: ____________________________________________                   Phone: (____)_________
   2. Street: _______________________________________________                   Apt #:      ________
   3. City: _____________________________________ State: ____                   Zip Code: ________
   4. E-mail Address: ______________________________________
H. Candidate’s Signature

I understand that the answers I give on this form will be kept confidential and will be used only to
determine my eligibility to participate in the IDA program. By signing below I give the IDA
program permission to obtain a consumer credit report on me and to contact outside agencies
and organizations in the process of establishing eligibility and setting up the IDA account.

I certify that I have not received the maximum allowable match from any ORR-Funded IDA
Program and the information given on this form is correct and complete to the best of my
knowledge. I am aware that if I provide false information, I may be terminated from the program
and will forfeit any match accrued.

Further, as a participant in this program, I hereby waive all claims, demands, and causes of
action of every nature arising from said participation in the above said program and or for the
release of information concerning me against Enterprise Development Group, its agents,
employees, officers, representatives, and/or program funders or evaluators.

In addition to the above, I agree to allow the Enterprise Development Group to use my name
and/or business name and photographs used for brochures, advertising, or any other business
related purpose in connection with publicity regarding the Individual Development Account
program. I also agree to be interviewed regarding my participation in the Individual Development
Account Program.

I understand that I will pay $50 to enroll in EDG ORR IDA program. This non-refundable
payment helps defray the costs of EDG’s operational costs.

Signature:     ____________________________ Date:____________

I. ECDC EDG IDA Manager Signature

The ECDC EDG IDA Manager listed below has verified the necessary documentation to
establish the candidate’s identification, eligibility status, income eligibility, employment status,
and parental (or guardianship) existence as necessary for business or educational savings
goals. If the candidate is approved to participate in the IDA program, a copy of this
documentation will be securely filed with the ECDC Enterprise Development Group
organization for tracking and auditing purposes.
For ECDC Enterprise Development Group

The IDA Manager Signature: ______________________ Date:                        ________

 INVEST in Your Future with ECDC EDG IDA                                                               4

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