APPLICATION for ASSISTANCE Today’s
Date: _________________
A copy of your most recent Income Tax Return(s) must be
provided with this application.
Please complete this form
IN YOUR OWN HANDWRITING. You must use
the CORRECT LEGAL NAME for each member of the household as it appears on their
Social Security Card. ALL adult members
of the household must sign this application certifying the accuracy of the
information.
Please Print
Applicant Name:
________________________________________________ Phone #’s (home): ___________________________
Co-Applicant Name:
________________________________________________ (applicant work
#): __________________________
Current Address:
_________________________________________________ (co-applicant work #):________________________
(City,
State, ZIP)
How long at this current address? _________ Amount of rent:
____________ Landlord Name:
______________________________
If less than 2 years at current address, give previous
address: ________________________________________________________
HOUSEHOLD
INFORMATION: Number of people in household: ______ Adults + ______ Children = TOTAL household
size:_______
Please list ALL adult household members who will be
living in the unit that receives assistance from our program.
Legal Name
(first, middle initial, last) Social
Security Number Date of Birth
1.
_________________________________________________ ___________________ _________________________
2.
_________________________________________________ ___________________ _________________________
3.
_________________________________________________ ___________________ _________________________
Please list ALL dependent children who will be living
in the unit that receives assistance from our program.
Legal Name
(first, middle initial, last) Social
Security Number Date
of Birth
1.
________________________________________________ ________________________ _________________
2.
________________________________________________ ________________________ _________________
3.
________________________________________________ ________________________ _________________
4.
________________________________________________ ________________________ _________________
5. ________________________________________________ ________________________ _________________
6.
________________________________________________ ________________________ _________________
Do you anticipate any change in family size within the next
12 months?______ Yes ______ No If yes, what change?
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
EMPLOYMENT INFORMATION: List all employers and any known potential employers of each
adult household member for the current tax year.
Employee ID Number Employer / Company Name
Name (household member) (usually the Social Security #) and Address (City, State, ZIP)
___________________________________________________ __________________________________________________
__________________________________________________
__________________________________________________ __________________________________________________
__________________________________________________
__________________________________________________ __________________________________________________
__________________________________________________
__________________________________________________ __________________________________________________
__________________________________________________
__________________________________________________ __________________________________________________
________________________________________________________
______________________________ _________________________ ________________________________________________________
________________________________________________________
______________________________ _________________________ ________________________________________________________
________________________________________________________
_____________________________ _________________________ ________________________________________________________
________________________________________________________
If any household member(s) listed above has been employed in
their current position(s) for less than 2 years, provide household member(s)
name and previous employer name(s) and address below.
_______________________________________________________________________________________________________________________.
_______________________________________________________________________________________________________________________.
_______________________________________________________________________________________________________________________.
_______________________________________________________________________________________________________________________.
_______________________________________________________________________________________________________________________.
Do you expect to receive any employment income(s) other than
those listed above in the next 12 months? ____Yes ____No
If yes, explain below.
_______________________________________________________________________________________________________________________.
_______________________________________________________________________________________________________________________.
_______________________________________________________________________________________________________________________.
_______________________________________________________________________________________________________________________.
_______________________________________________________________________________________________________________________.
INCOME
INFORMATION: List all
money currently being earned or received by everyone living in your household.
This includes money from wages, self-employment, child support, Social Security
(including Medicare), disability income, workmen’s compensation, retirement
benefits, Aid to Dependent Children, veteran’s benefits, rental property
income, investment income (including stocks, dividends and interest from all
bank accounts), unemployment benefits and any other sources.
Name (Household Member) Type of Income Source Amount
_____________________________________ _____________________ _____________________________________ ________________
_____________________________________ _____________________ _____________________________________ ________________
_____________________________________ _____________________ _____________________________________ ________________
_____________________________________ _____________________ _____________________________________ ________________
_____________________________________ _____________________ _____________________________________ ________________
_____________________________________ _____________________ _____________________________________ ________________
ASSET
INFORMATION: For all
“yes” answers, please complete “Asset Detail” information below.
1. Does anyone in the household own or have interest in any
real estate, mobile home or personal property (gems, jewelry,
antiques, boats,
etc.) held as an investment? ___Yes ____No
2. Has anyone in the household sold any real estate in the
last 2 years? ___Yes ____No
3. Does anyone in the household have any savings accounts,
CD’s or Money Market Funds? ___Yes ____No
4. Does anyone in the household own any stocks and/or bonds? ___Yes ____No
5. Does anyone in the household have bank checking accounts? ___Yes ____No
6. Does anyone in the household own any types of motor
vehicles? How many vehicles? ___Yes ____No
Asset Detail:
Name (household member) Type
& Location of Asset Estimated
Value
_____________________________________________ ____________________________________________________ ________________
_____________________________________________ ____________________________________________________ ________________
_____________________________________________ ____________________________________________________ ________________
_____________________________________________ ____________________________________________________ ________________
_____________________________________________ ____________________________________________________ ________________
7. Is the
household currently, or ever been, involved in any litigation or legal action
concerning delinquency of payment of taxes,
loan payments, etc., any place within the
United States? If yes, explain
below. ___Yes ____No
8. Has any
member of the household disposed of any asset during the past 2 years? If yes, explain below. ___Yes ____No
9. Has any
adult member of the household ever used any name(s) or Social Security
Number(s) other than those currently being
used?
If yes, explain below. ___Yes ____No
10. Has any
member of the household previously lived in any type of assisted housing? If
yes, explain below. ____Yes
____No
_______________________________________________________________________________________________________________________.
_______________________________________________________________________________________________________________________.
_______________________________________________________________________________________________________________________.
_______________________________________________________________________________________________________________________.
_______________________________________________________________________________________________________________________.
11. Has any
member of the household ever been asked to repay money for knowingly
misrepresenting information or
committing fraud with regard to any
Federally assisted housing program? If
yes, explain below. ___Yes ____No
12. Does
anyone in the household receive income other than what is taxable income listed
on tax returns? If yes, explain below. ___Yes ____No
13. Does
anyone outside the household pay for any of the household expenses or give you
money? If yes, explain below.
___Yes ____No
_______________________________________________________________________________________________________________________.
_______________________________________________________________________________________________________________________.
_______________________________________________________________________________________________________________________.
14. If you have any further information you want considered,
in this application, regarding income or expenses, please explain below and
include documentation with this application.
_______________________________________________________________________________________________________________________.
_______________________________________________________________________________________________________________________.
_______________________________________________________________________________________________________________________.
OPITIONAL
HOUSEHOLD CHARACTERISTICS: The following demographic information is
strictly optional and has NO bearing on eligibility for participating in our
program.
Marital Status: ____ Single
____ Married Head of Household: ____ Male ____ Female umber
of older adults (62+): _______
Are any members of your household disabled? ____Yes
____ No If yes, number of
people with disabilities: __________________
Race (applicant):
____Caucasian ____African
American ____Hispanic ____Native American ____Asian ____Other
Race (co-applicant):
____Caucasian ____African
American ____Hispanic ____Native American ____Asian ____Other
APPLICANT
CERTIFICATION:
I/We certify that a complete copy of the Program Guidelines,
for the type(s) of assistance I/we are applying, has been provided for our
personal reference. I/We have read and understand all the terms as outlined in
the Program Guidelines.
I/We certify that the information provided to Wayne
Community Housing Development Corporation (WCHDC) on this application is
accurate and complete to the best of my/our knowledge and belief. I/We
understand that false statements or information are punishable under Federal
and/or State Law and that false statements or information are grounds for
termination of any further consideration or assistance under any program
offered by WCHDC.
In the event that my/our household financial circumstances
change prior to closing and signing a Loan Agreement, I/we will notify WCHDC
within ten (10) days of the change and resubmit the “Application for
Assistance” for review and approval.
Signature of Applicant:
______________________________________________________________Date:
______________________
Signature of Co-Applicant:
___________________________________________________________Date:
______________________
