Full Name: Property address: City: State: ZIP Code: Mailing address: City: State: ZIP Code: Own Rent How long? Monthly Housing payment: $ Cell: Home: Work: Date of birth: SSN: Email: Race (HUD requires clients to report all below Demographic Information): American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Pacific Islander White American Indian/Alaskan Native & Black American Indian/Alaskan Native & White Asian & White Black/African American & White Other: Ethnicity (check one): Hispanic Not Hispanic Gender (check one): Female Male Other: Country of Origin: Preferred Language: Highest Education Completed (check highest): Less than High School Completion GED Diploma Associate’s Degree Master’s Degree High School Diploma Vocational Certificate Bachelor’s Degree Doctoral Degree Household Type (check one): Female Headed Single Parent Married with Dependents Two or more unrelated adults Other: Male Headed Single Parent Married without Dependents Single Adult Check all that apply Disabled US Veteran Household size: Number of Dependents: Estimated Household Monthly Income: Referred by: Internet Word of Mouth Government Bank Realtor Other: CO-PARTICIPANT
Full Name: Property address: City: State: ZIP Code: Mailing address: City: State: ZIP Code: Own Rent How long? Monthly Housing payment: $ Cell: Home: Work: Date of birth: SSN: Email: Race (HUD requires clients to report all below Demographic Information): American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Pacific Islander White American Indian/Alaskan Native & Black American Indian/Alaskan Native & White Asian & White Black/African American & White Other: Ethnicity (check one): Hispanic Not Hispanic Gender (check one): Female Male Other: Country of Origin: Preferred Language: Highest Education Completed (check highest): Less than High School Completion GED Diploma Associate’s Degree Master’s Degree High School Diploma Vocational Certificate Bachelor’s Degree Doctoral Degree Household Type (check one): Female Headed Single Parent Married with Dependents Two or more unrelated adults Other: Male Headed Single Parent Married without Dependents Single Adult Check all that apply Disabled US Veteran Household size: Number of Dependents: Estimated Household Monthly Income: Referred by: Internet Word of Mouth Government Bank Realtor Other: Privacy Policy Housing Initiative Partnership (“HIP”) is committed to assuring the privacy of individuals and/or families who have contacted us for assistance. We realize that the concerns you bring to us are highly
Name(s) ______________________________ Loan #_____________________ Address___________________________________________________________ A. Household Expenses: Fixed Monthly Expenses: Payment: Mortgage 2nd Mortgage Condo / Homeowner Association Fees Gas & Electric Heating Oil Water & Sewer Telephone Car Payment 1 Car Payment 2 Auto Insurance Life Insurance Medical Insurance Alimony / Child Support Alarm System Property Taxes/Insurance Other/Minimum Credit Card Payment from Section C Sub-Total FIXED Expenses: Variable Monthly Expenses Payment Groceries Eating Out Gas Bus/Taxi/Parking Car Repairs Toiletries/Hair Care Medical Prescriptions Day Care Cable TV/Internet Clothing/Laundry Lottery Church/Charity Entertainment Cell Phone Other Sub-Total, VARIABLE Expenses: Total Monthly Expenses: B. Your Monthly Income: Gross Income: Net Income (after taxes and deductions): $ $ Spouse or Partner’s Income Gross Income: Net Income (after taxes and deductions): $ $ Other Household Income: Gross Income: Net Income (after taxes and deductions): $ $ Describe: C. Credit Cards and Other Debt: Creditor Name: Payment: Balance: Total $ $ D. Surplus/Deficit: Total Net Monthly Household Income: $ Subtract Total Monthly Expenses: $ = Monthly Surplus or Deficit $ Signature:__________________________ Date: ___________________________