WESTERN DAIRYLAND HOUSING COST REDUCTION INITIATIVE AND NSP/FRESH START APPLICATION

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1 WESTERN DAIRYLAND HOUSING COST REDUCTION INITIATIVE AND NSP/FRESH START APPLICATION Social Security No. Applicant(s) (First Name) (Middle Initial) (Last Name) Address_ (Street) (City) (County) (Zip code) Telephone (Home) (Work) (Alternate) Race White Asian Black/African American American Indian/Alaskan Native Native Hawaiian/Other Pacific Islander American Indian/Alaskan Native & White Black/African American & White Asian & White American Indian/Alaskan Native & Black/African American Other Multi-racial Ethnicity FHOH Female Head of Household PD Households with Persons with Disabilities E Elderly HM Homeless Prevention (Foreclosure, Eviction Prevention) SP/CH Single Parent w/children LF Families with 4 or more Minor Children H Hispanic (Should also indicate race) PLEASE LIST ALL HOUSEHOLD MEMBERS, INCLUDING APPLICANT Name Age Sex Name Age Sex Page 1 of 7

2 Are you participating in a W-2 Wisconsin Works Employment Program? Yes Are you receiving TANF cash benefits? Yes Do you receive Food Stamps? Yes Medical Assistance? Yes Wisconsin Shares (Child Care Assistance)? Yes Do you receive services from another agency/organization? Yes If yes, please list: Agency/Organization Services Provided Case Mgr/Social Worker Telephone INCOME ELIGIBILITY Please list below all persons who live in your household. List the incomes of all persons 18 years of age or older. Income includes, but is not necessarily limited to, income from all gross wages, salaries, commissions, net income from self-employment, net income from the operation of real property, interest and dividend income, Social Security, SSI, pensions, AFDC, alimony, child support and other benefit income. INCOME: Total Household Gross Income for last 6 months or previous year from time of application Income must be verified with previous year tax returns, letter from employer, bank statements, etc. Family Member a. Wages/ Salaries b. Business Income ANNUAL INCOME c. Interest/ Dividends d. Benefits/ Pensions e. Public Assistance f.other income define: i.e. child support, etc. 1.Totals a. b. c. d. e. f. 2. Enter total of items from 1a. through 1f. This is Annual Income. Time Period of through month/day/year month/day/year Do you have a savings plan to buy a home? Yes Do you have outstanding loans/debts for: Car loans Credit cards Major household purchase Other Page 2 of 7

3 What is your estimated outstanding debt? $ Do you feel you have a good credit rating? Yes ASSET INFORMATION List the cash value of assets held by all residents 18 years and older in your household. Checking account Institution, Address and Account Number: Savings Account Institution, Address, and Account Number: Cash value of Securities or U.S. Savings Bonds: CURRENT HOUSING How long have you lived at your present address? Number of years Do you live in apartment house duplex mobile home Do you rent or own your own home? rent own If you currently own a mobile home, is it attached to property which you own? Yes What is your current monthly rent or mortgage payment? $ \ Do you pay utilities (heat, electricity, water)? Yes If yes, how much do you pay per month for all utilities? $ Budget Plan $ Lowest bill $ Highest bill $ Do you consider your residence to be safe and sanitary? If not, please explain: Is there a situation which requires you to move from your current residence within the next three months? Please explain: Have you ever owned a home or mobile home? Yes If yes, when? Page 3 of 7

4 If you owned a mobile home, was it attached to property which you owned? Yes Does anyone in your household currently own any real estate property such as a house, investment property, cabin or cottage? Yes Are you related to anyone employed or on the Board of Directors at Western Dairyland? Yes Will this house be your primary residence? Yes HOUSING NEEDS/PREFERENCES How long have you wanted buy your own home? Have you received any: home ownership counseling budget/financial counseling? Have you read any books on home ownership or buying a home? Have you: looked at homes contacted a realtor contacted a bank? Have you contacted any other agencies about getting assistance in purchasing a home? Explain: Have you found a home you wish to buy? Yes What features in a home are important to you? (number of bedrooms, garage, backyard) Explain: In what city, town or county would you like to purchase a home? Are there any special facilities which would make a home more accessible for a member(s) of your family with special needs? Yes Explain: Please feel free to share with us any other information you think would help us in assisting you to purchase a home. Where did you hear about Western Dairyland s Homebuyer Assistance Program? Page 4 of 7

5 I HEREBY CERTIFY THAT THE INFORMATION ON THIS APPLICATION IS TRUE AND CORRECT. I UNDERSTAND THAT INFORMATION ON THIS APPLICATION IS BEING GIVEN IN CONNECTION WITH THE RECEIPT OF FEDERAL FUNDS AND THAT DELIBERATE MISREPRESENTATION MAY SUBJECT ME TO PROSECUTION UNDER APPLICABLE STATE AND FEDERAL STATUTES. SIGNATURE OF APPLICANT: SPOUSE DATE DATE Page 5 of 7

6 To Whom It May Concern: GENERAL RELEASE OF INFORMATION I/We have applied to Western Dairyland and hereby authorize you to release to Western Dairyland EOC, Inc. the requested information listed below: 1. Previous and past employment history, including employer, period employed, title of position, income and hours worked; also, disability payments, social security, and pension funds. 2. Any information deemed necessary in connection with a consumer credit report or a real estate transaction. 3. I acknowledge that Western Dairyland EOC, Inc. may need to release, to receive, or to exchange confidential information, related to my application and participation with itself and/or public agencies providing services to my family for purpose of determining eligibility. These lending and/or public housing agencies and Western Dairyland EOC, Inc. are bound by confidentiality requirements. This information will be for the confidential use of Western Dairyland EOC, Inc. in determining my/our eligibility for assistance or to confirm information I/we have supplied. Please complete the attached verification request. A photo or fax copy of this document may be deemed to be the equivalent of the original and may be used as a duplicate original. The original signed release of information will be kept on record with Western Dairyland. Last, First, M.I. Last, First, M.I. Social Security # Social Security # Street Address City, State, Zip Code Street Address City, State, Zip Code Signature Signature NOTICE TO GRANTEES: This notice to you is required by the Right to Financial Privacy Act of The Department of Housing and Urban Development, Federal Housing Administration or Veterans Administration have a right of access to financial records held by financial institutions in connection with the consideration or administration of assistance to you. Financial records involving your transaction will be available to HUD, FHA, DOA or VA without further notice or authorization but will not be disclosed or released by this institution to another government agency without your consent except as required by law. Page 6 of 7

7 CONFLICT OF INTEREST STATEMENT As part of your application for down payment/closing costs or mortgage assistance, it is necessary that you disclose any conflict of interest. A conflict of interest occurs when an employee or board member of Western Dairyland is in a decision-making position and has a direct or indirect interest, particularly a substantial financial interest. Please indicate below if you have any family or business ties to any covered persons. Family includes spouse, children, siblings, parents, grandparents, in-laws, or anyone who receives more that 50% of their support from the covered person. Covered Persons include employees, board members, or consultants who are in positions to participate in decision-making process or gain inside information with regard to housing activities, either for themselves or those with whom they have family or business ties. Do you have family or business ties to any covered person as described above? YES NO If yes, please indicate the name of the covered person: What is your relationship to the covered person? The undersigned hereby certifies that the conflict of interest statement and information provided is true to the best of their knowledge. The undersigned also certifies that they fully understand that they are able to choose any services, lending products or forms of assistance without influence from Western Dairyland. Applicant Signature Co-Applicant Signature Complete this section for Down Payment/Closing Cost only MARITAL PROPERTY STATEMENT No provision of a marital property agreement (including a Statutory Individual Property Agreement pursuant to Sec , Wis. Stats.) unilateral statement of classifying income from separate property under Sec or court decree under Sec , adversely affects the creditor unless the creditor is furnished with a copy of the document prior to the credit transaction or has actual knowledge of its adverse provisions at the time the obligation is incurred. Applicant Signature Co-Applicant Signature Page 7 of 7

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