PREQUALIFICATION WORKSHEET by hmb46803

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									                      PREQUALIFICATION WORKSHEET

                                                   County Where You Live: _________________
                                                                                 How Long: ________
Applicant Information:                             Date of Birth: __________________________________

Name: ________________________________             SS# :__________________________________________
Address: ______________________________            Home Phone: _________________________________
______________________________________             Work Phone: __________________________________

Co-Applicant Information:                          Date of Birth: _________________________________
Name: ________________________________             SS# :__________________________________________
Address: ______________________________            Home Phone: _________________________________
______________________________________             Work Phone: __________________________________

Other Household Members: (Adult is defined as a household member 18 yr of age or older)
Adult Name: ____________________________ Age: _____ Income: $_____________ Full Time Student: (y/n)
Adult Name: ____________________________ Age: _____ Income: $_____________ Full Time Student: (y/n)
Adult Name: ____________________________ Age: _____ Income: $_____________ Full Time Student: (y/n)
Children- Full Name: ___________________________ Children- Full Name: ___________________________________
Children- Full Name: ___________________________ Children- Full Name: ___________________________________
Children- Full Name: ___________________________ Children- Full Name: ___________________________________

GROSS INCOME:         $                            Name of Employer: ________________________________
Wage/Salary Income:   $                                 Public Assistance : $ ____________________________
Child Support:        $                                 Unemployment: $______________________________
Foster Care:          $                               AFDC/TANF: $ __________________________________
Pension:              $                                Social Security: $________________________________

ASSETS:
Checking Account Balance: $____________________ Savings Account Balance: $________________________

Monthly Debts:
Auto Loan           ______________________/moCredit Cards         ______________________/mo
Auto Loan           ______________________/moCredit Cards         ______________________/mo
Child Support Paid  ______________________/moCredit Cards         ______________________/mo
                    ______________________/moOther
Medical Debts/Expenses                                            ______________________/mo

1) Are you willing to Partner with Hanover Habitat for Humanity (200 volunteer hours)? _______
2) Explain the reason your living conditions are inadequate: ___________________
_______ a) Unsafe Housing: ______ Electrical Problems _____ Plumbing Problems/No Indoor Problems
           _____No working heat source _______Rotting Floors/windows ______ Drafts/No insulation
             _____ Other: _______________________________________________________
________ b) Over Crowding:
________ c) Current Rent $ __________________ /mo Excessive for Income
_______ d) Other: (explain) ___________________________________________________________

Best time and number to call: _____________________________________________

PLEASE INCLUDE $15 FOR A CREDIT REPORT FOR EVERY ADULT IN THE HOUSEHOLD.

								
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