Initial Screening Form - Habitat for Humanity of Hillsborough County, FL

Habitat for Humanity of Hillsborough County works to acquire affordable residential building lots throughout Hillsborough County. We offer home sites as land opportunities become available to us. **VETERANS are urged to apply through the VETERANS INITIAL SCREENING FORM.**
To be eligible for this program, you must have lived OR worked in Hillsborough County for the last 12 consecutive months. It can be one or the other or both. You must also have steady, verifiable income from a job OR other sources. This can include disability pay or retirement pay.
Applicant Name*
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Daytime Phone*
Email*
Co-Applicant Information
Is there a co-applicant?*
- Yes
- No
Co-Applicant Name
First Middle Last
Co-Applicant Daytime Phone*
Co-Applicant Email*

If approved, how many people would be living in the Habitat home (INCLUDE APPLICANT OR CO-APPLICANT!)?*
Please enter a number from 1 to 10.
Please provide the gender and ages of all those who will be living with you. DO NOT INCLUDE Applicant or Co-Applicant.
Number of Males (DO NOT INCLUDE APPLICANT OR CO-APPLICANT!)*
Ages of Males (DO NOT INCLUDE APPLICANT OR CO-APPLICANT!)
Number of Females (DO NOT INCLUDE APPLICANT OR CO-APPLICANT!)*
Ages of Females (DO NOT INCLUDE APPLICANT OR CO-APPLICANT!)

Total Household Monthly Income
List your TOTAL GROSS MONTHLY INCOME FOR YOUR HOUSEHOLD, including the income from all those 18 and older WHO WILL BE LIVING IN THE HOME. Include income from these sources: Wages (before taxes and deductions), Social Security income, alimony, child support you receive, disability, and any other regular monthly income. Please list each different type of income along with the monthly amount:
GROSS MONTHLY WAGES (BEFORE taxes/deductions). INCLUDE all wages of persons 18 & older in household.
INCOME from Social Security - NOT YOUR SOC SEC NUMBER!! (include SSI, SSD, etc.) DO NOT LIST YOUR SOCIAL SECURITY NUMBER HERE!!
DO NOT LIST ANY SOCIAL SECURITY NUMBERS!!!
Alimony RECEIVED Monthly
Child Support RECEIVED Monthly
VA Disability and/or Retirement or Pension Income (INCLUDE amounts of all persons receiving VA disability income or Retirement/Pension income)
Do you have any other income sources?*
- Yes
- No
If yes, what is the source of your other income?
How much do you make each month from your other income source?
Do you, the Applicant, and/or the Co-Applicant, if applicable, have any NON-MEDICAL collections or bad debts? (e.g. car repossessions, defaulted loans or credit cards, defaulted rental housing, etc.)*
- Yes
- No
If you checked YES, above, for non-medical collections, is the TOTAL of the non-medical collections more than $1,500?
- Yes
- No

*
- I have read the Habitat Hillsborough Privacy Notice and eCommunications Agreement.
By submitting this form, I affirm that the information on this form is true and correct. I understand that providing false information could cause me to be disqualified from the Habitat program. I authorize the verification of the information provided on this form as to my credit, employment, income and background, including criminal background checks. I have received a copy of this Initial Application. I understand that, based on the information I provided, if my Initial Application meets Habitat Hillsborough’s basic criteria, I will be invited to submit a full Homeownership Program application. If it does not meet basic criteria, I understand that I will receive an Adverse Action letter. Further, I acknowledge that if I am able to submit a Habitat Homeownership Program Application, and an appraisal is ordered in connection with that application, I will be provided a copy of that appraisal at no cost to me.
Date*
MM slash DD slash YYYY
Applicant E-Signature*
Co-Applicant E-Signature*
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

Co-Applicant Information