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Application for Homebuyers

Looking for a home, trying to improve your credit rating, or seeking to avoid foreclosure on the home you already own? Counselors at Adirondack Roots can provide free assistance. Complete this form and we’ll contact you shortly.

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- Step 1 of 7

Bills Supplies) Expense

Why are you interested in meeting with a Housing Counselor? *

Want to purchase a home
Post-home purchase budgeting
Establish/Improve Credit
Prevent Foreclosure on Current Home

Check all that Apply

Where would you like to purchase a home? *

Town & County

Applicant – General Information

Name *

First

Middle

Last

Home Address *

Address Line 1

City

State

Zip Code

Do you have a different mailing address? *

Yes
No

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Cell Phone

Work Phone

Date of Birth *

Email *

Race / National Origin

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

Foreign Born *

Yes
No

Permanent Resident *

Yes
No

Citizen *

Yes
No

Marital Status *

Single
Married
Divorced
Separated
Widowed

Gender *

Male
Female

Disabled *

Yes
No

Veteran *

Yes
No

Highest Level of Education *

Below High School
High School/GED
2 yr. College
Bachelor’s Degree
Master’s Degree

Special Needs Assistance Requests

Hearing Impaired
Visual Impairment
Accessibility
Limited English Proficiency
Language Translation
Other

Language Translation: please specify

Other Special Needs Assistance: please specify

Referred to by

Bank
Government
Print Advertisement
Realtor
Friend
Newspaper
Radio
Staff/Board Member
Walk-In
TV
Other

Other Referred: please specify

Co-Applicant – General Information

Is there a Co-Applicant? *

Yes
No

Co-Applicant Name *

First

Middle

Last

Home Phone *

Cell Phone

Work Phone

Social Security Number *

Date of Birth *

Race / National Origin

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

Foreign Born *

Yes
No

Permanent Resident *

Yes
No

Citizen *

Yes
No

Marital Status *

Single
Married
Divorced
Separated
Widowed

Gender *

Male
Female

Disabled *

Yes
No

Veteran *

Yes
No

Highest Level of Education *

Below High School
High School/GED
2 yr. College
Bachelor’s Degree
Master’s Degree

Co-Applicant Relationship to Applicant *

Household Information

Have either applicant(s) owned a home in the last 3 years *

Yes
No

Household Type *

Single parent household
Married with children
Married without children
Single adult
Two or more unrelated adults
Other

Please select the most accurate

Other Household: please specify *

No. of People living in the household *

List Household Members *

Applicant – Employment Information

Please list all employment in the past 2 years

Current Primary Employer *

Title *

Hire Date *

Phone

Employment Type *

Gross Income (before taxes) $ *

Is this amount paid... *

Co-Applicant – Employment Information

Please list all employment in the past 2 years

Co-Applicant Current Primary Employer

Title

Hire Date

Phone

Employment Type

Gross Income (before taxes) $

Is this amount paid...

Sources of income for ALL members of the household

List monthly amount

Social Security $

Child Support $

Pension / Retirement $

Disability $

Unemployment $

Other $

Section 8 Voucher Information

Do you currently receive Housing Choice Voucher (Section 8) rental assistance from HAPEC or another agency? *

Yes
No

If yes, what agency?

Name of case worker?

Household Budgeting Worksheet

Make sure that you include all income and expenses as accurately as possible. The information you provide will be used to compute your household income and eligibility for any programs we may offer. Try not to inflate or underestimate numbers.

Monthly Income

Salary/Wages $ *

Salary/Wages (Spouse) $ *

Social Security $ *

Military Pay $ *

Pension Plan / Retirement $ *

Interest Income $ *

Alimony / Child Support $ *

Real Estate (Rent) $ *

Dividends (Investments) $ *

Unemployment / Food Stamps $ *

Royalties / Other income $ *

Total Income $

Monthly Living Expenses

Food (Home, Work, School) $ *

Household Items $ *

Clothing $ *

Laundry / Dry Cleaning $ *

Telephone (Home, Cell, Pager) $ *

Internet Service $ *

Cable TV / Satellite $ *

Electric $ *

Gas / Oil $ *

Water / in-Horne Service $ *

Trash Service $ *

Auto Gas / Maintenance $ *

Auto Insurance $ *

Health & Dental Insurance $ *

Life & Disability Insurance $ *

Homeowners / Renters Insurance $ *

Education (Tuition, Supplies) $ *

Personal Care (Hair, Nails, etc) $ *

Medical Care (Prescriptions, etc.) $ *

Child Care (Nanny, Day Care) $ *

Children Activities (Sports, etc.) $ *

Alimony / Child Support $ *

Gardener/Pool/Alarm Service $ *

Entertainment $ *

Homeowner Dues $ *

Subscriptions $ *

Health Club Membership $ *

Contributions / Donations / Gifts $ *

Other Expenses (Misc.) $ *

Total Expenses $

Montly Debts

Rent (Apartment, etc) $ *

1st Mortgage; Taxes / Insurance $ *

2nd Mortgage; Taxes / Insurance $ *

Trailer Park Space Rent $ *

Student Loans $ *

Auto Loans / Leases $ *

Recreation Toys (Watercraft, etc.) $ *

Past-Due Taxes $ *

Other Secured Debts $ *

Other Secured Loans $ *

Total Secured Debt $

Monthly Unsecured Debts

Credit Card *

Credit Card *

Credit Card *

Credit Card *

Credit Card *

Credit Card *

Personal Loan *

Personal Loan *

Medical / Dental Bills *

Other Unsecured Loans *

Total Unsecured Debt

Summary of Budget

Note: If you have a deficit, our counselors can help you create a workable budget to help you reach your financial goals.

Total Take-Home Income *

Total Living Expense Payments *

Total Secured Debt Payments $ *

Total Unsecured Debt Payments $ *

Your Disposable Income or Deficit $ *

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 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 Housing Assistance Program of Essex Co., Inc. Such information may be shared with financial institutions for the purpose of pre-approval or financing/purchasing a home.

Applicant Signature

Signature *

Clear Signature

Date *

Co-Applicant Signature

Signature *

Clear Signature

Date *

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 *

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103 Hand Avenue
PO Box 157
Elizabethtown, NY 12932

Phone: 518-873-6888
Fax: 518-873-9102
info@adirondackroots.org

NW CHARTERED WHITE

As part of the NeighborWorks network, Adirondack Roots is among the nation’s best community development and affordable housing organizations.

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