EmailMeForm
PRE-SCREENING APPLICATION
1. I have a need:
Please indicate for which program you are applying:
Home Repair Program
Homeownership Program
If applying for the Home Repair Program, please list
what repairs are needed (use a separate sheet of paper if
necessary.)
Please review our income guidelines. You must fall within the yearly income range for your family size.
1 - $31,600 - $32,550
2 - $36,100 - $37,200
3 - $40,600 - $41,850
4 - $45,100 - $46,500
5 - $48,750 - $50,250
6 - $52,350 - $53,950
7 - $55,950 - $57,700
8 - $59,550 - $61,400
2. I have the ability to pay (Please select all that apply)
Have you declared bankruptcy in the past 2 years?
Yes
No
If yes, please give the date of bankruptcy and date of discharge:
Do you pay your rent and other bills on time?
Yes
No
Do you have any outstanding judgments (must pay off prior to application)?
Yes
No
Do you have a stable income that can be verified by pay stubs or letter for the last two years?
Yes
No
Have you been notified that your continued income will be terminated or lessened?
Yes
No
3. I am willing to partner with Habitat
Have you lived and/or worked in Hamblen or Grainger County for at least one year?
Yes
No
Can you provide proof of citizenship or Permanent Residency Status?
Yes
No
Are you willing to partner with Habitat and work at least 300-400 hours of “sweat equity”, attend budget counseling and homeowner workshops, participate in Habitat events, participate in all application evaluation steps, provide all application information in a timely, honest manner and demonstrate a strong commitment to Habitat’s goals?
Yes
No
Contact Information
Full Name
*
Street Address
City
State
ZIP
Date of Birth
Age
Marital Status *
Married
Unmarried
Divorced
Legally Separated
* Legal Documentation May be required.
Are you a Veteran or a current member of the U.S. Arm Forces?
Yes
No
If yes, were you honorably discharged?
Yes
No
If yes, are you disabled?
Yes
No
Home Phone
Cell Phone
Work Phone
Please list the co-applicant, if applicable:
Co-Applicant
Street Address (if different from above)
City
State
ZIP
Date of Birth
Age
List ALL sources of income. You must include source of income, amount BEFORE TAXES, and times paid per month (weekly, biweekly, etc.)
Other acceptable sources of income are: Social Security, Disability, Retirement, and Child Support
Documentation for these will be required and will be verified by Habitat Staff.
Example:
Jane Doe, Company Name, $350, Biweekly
Information regarding Credit, Criminal, and Background Verification:
Have you ever been convicted of a felony?
Yes
No
If yes, explain conviction and penalty below. Include
dates of conviction and incarceration.
Has any other member of the household been convicted of a felony?
Yes
No
If yes, explain conviction and penalty below. Include dates of conviction and incarceration.
Please explain other circumstances regarding your or your family’s background, credit, or criminal check that you feel needs explanation:
Release: By my signature, I affirm that all of the information provided in this document is true. I further, by my signature, consent to a thorough Background Check including, but not limited to, Credit History, Employment History, Criminal History, Social Security verification and Permanent Residency Status. I understand that the information provided will be kept confidential. I further agree that false statements on this form will eliminate my eligibility to participate in this program.
Applicant
*
By typing your name in the box above you understand that it servers as a legal signature.
Co-Applicant (if applicable)
Date Time
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