Applications & Forms

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Applicant Information

Name *

First

Last

Mailing Address *

Address Line 1

City

State

Zip Code

to Name Rate

Mobile Phone *

Other Phone

Email Address *

Family Composition

List each family member who will live in the new dwelling:

Name *

Relationship *

Age *

Birthdate *

Sex *

Total number of persons to live in the new home:

Total number of persons to live in the new home: *

Is the Applicant a...

US Citizen *

US Veteran *

Is the Co-Applicant a...

US Citizen

US Veteran

Employment

Complete for each job held by each family member. Please provide information for where you are employed now, or if seasonal, please note.

Name *

Position/Title *

Employer *

Phone *

Rate or Monthly Gross Salary: $ *

Annual Amount: $ *

How many years in this type of work *

Other Income

If a single family member has more than one source of income, use a separate line for each source.

Name

Amount per (WK/MO)

Source of Income

Annual Amount

Assets

Please list assets such as checking accounts, savings accounts, stock, real estate owned, that are not considered income.

Institution

Type of Account

Current Balance

Current Housing

How long have you lived in your current home?

Years *

Months *

Have you been a home owner in the past three years? *

Do you currently receive Section 8 rental assistance? *

How much do you pay in monthly rent? *

Provide information for utilities which are not included in your rent and that you pay.

Electric (per month) *

Oil (per month) *

Gas (per month) *

Water (per month) *

Other (per month) *

List your addresses and landlords for the past five years.

Landlord *

Address *

Address Line 1

City

State

Zip Code

Mortgage Information

Complete for property you presently own.

Date purchased

Purchase price

Are tax payments current?

First Mortgage

Original Amount

Balance Due

Term Percentage

Term Years

Are mortgage payments current?

Mortgage Holder

Land Contract

Original Amount

Balance Due

Term Percentage

Term Years

Are mortgage payments current?

Contract Holder and Address

Identify any other Real Estate you own

Liabilities and Fixed Debts

List all liabilities such as car payments, recreational equipment loans, credit cards debt, child support, alimony, judgments, and any other scheduled payments.

Do you have any liabilities and fixed debts? *

Debt Type *

Balance *

Mo. Payment *

Mo. Remaining *

Do you pay for child care? *

Please provide the following for each child.

Name

Age

Hrs/Wk

Rate per hour

Cost per week

Voluntary Information for Reporting Purposes

The following information is requested by the Federal Government in order to monitor compliance with Federal laws prohibiting discrimination against applicants on the basis of race, national origin, and sex. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way.

Race/National Origin

White
Black
Hispanic
Asian or Pacific Islander
American Indian or Alaskan Native

Marital Status

Married
Separated
Unmarried (Single, divorced, or widowed)

Disabled

Type of Household

Single/non-Elderly
Elderly
Related/Single Parent
Related/Two Parent
Other

IMPORTANT - READ BEFORE SIGNING

I/we certify that to the best of my (our) knowledge and belief the above data is true and correct. I/we further consent to the release of credit information (at no cost to me) that may be available from a credit reporting agency and delivered directly to Adirondack Roots. Such information may be shared with financial institutions for the purpose of pre-approval or financing/purchasing a home.

Applicant

Date *

Signature *

Clear Signature

Co-Applicant

Date

Signature

Clear Signature

WARNING - Federal Law makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the U.S. as to any matter within its jurisdiction.

Please prove that you are human by solving the equation *

ACHT Eligibility Form

Applicant Information

Family Composition

Total number of persons to live in the new home:

Is the Applicant a...

Is the Co-Applicant a...

Employment

Other Income

Assets

Current Housing

How long have you lived in your current home?

Mortgage Information

First Mortgage

Land Contract

Liabilities and Fixed Debts

Voluntary Information for Reporting Purposes

IMPORTANT - READ BEFORE SIGNING

Applicant

Co-Applicant