Home Phone
Date
Work Phone
Applicant:
Social Security #
Co- Applicant:
Social Security #
Mailing Address:
City & State
Number of Dependents
Is anyone in your
household disabled?
Are you a U.S. Citizen?
Rent $:
Own:
Current Living Situation:
Other:
HOUSEHOLD AND INCOME INFORMATION
(Please include information on everyone in household)
Name:
mm/dd/yy
Age-Date of Birth:
Gross Annual Income:
Length of Employment:
Name:
mm/dd/yy
Age-Date of Birth:
Gross Annual Income:
Length of Employment:
Name:
mm/dd/yy
Age-Date of Birth:
Gross Annual Income:
Length of Employment:
Name:
Age-Date of Birth:
mm/dd/yy
Length of Employment:
Gross Annual Income:
Include Food Stamps or
Child Support if applicable:
List any additional income:
Child Care Expenses:
Debt Information:
List all debts (car payments, furniture, credit cards, student loans, bank notes, etc.) Do not include living expenses, such as rent and utilities.
Creditor:
Monthly Payment:
Balance Owing:
Creditor:
Monthly Payment:
Balance Owing:
Creditor:
Monthly Payment:
Balance Owing:
I affirm that all the answers given in this pre-application are correct and made for the purpose of obtaining credit. I authorize Deep Fork Self Help Housing to
communicate with any person, firm or corporation needed, including Rural Development, to obtain such information as may be required concerning the statements made
in this pre-application interview and agree that the pre-application shall remain the property of Deep Fork Self Help Housing whether or not the loan herein requested is
granted.
Signature:
Please type your name(s) in the box(s)
to signify you have signed the form.
Signature:
Your email address:
Comments:
