Individual Development Account (IDA) Program

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1 Individual Development Account (IDA) Program IDA Program Pre-Application Form Site: I would like to become a Participant in Neighborhood Housing Services of New Haven s IDA Program. Name: Phone (Daytimes): (Evening): (Cell): Family Information: Gender: Male Female Marital Status (Please circle one): Married Single Separated Divorced Widowed Number of Dependents: You must meet income eligibility and other requirements to be accepted into the IDA Program. IDA Program staff will make the final determination as to whether you are eligible for the Program. A member of the IDA Program staff will call you shortly to set up an appointment. Thank you for your interest in Neighborhood Housing Services of New Haven s IDA Program.

2 Individual Development Account (IDA) Program IDA Program Application Form Site: Participant s Social Security No: Participant s Name: Phone (Daytime): (Evening): Date of enrollment in IDA Program: Date of birth of Participant: Referring source: Please provide the name and address of a relative who would definitely know where you live even if you move: Relative s Name: Phone (Daytime): (Evening): Gender of Participant: Female Male

3 Ethnicity of Participant: African-America Caucasian Latino/a or Hispanic Asian/Pacific Islander Native American Other (Please specify) Marital Status: (Please circle one.) Married Single Separated Divorced Widowed How many adults (18 years and older) currently live in your household: How many children (under 18 years) currently live in your household: Age and Gender of children: Highest level of education completed by participant: Grade K-5 Grade 6-8 Grade 9-12 High School diploma or GED Attended College Graduated College Attended Graduate School Employment status of Participant: Employed more than full-time (OT, or working more than one job) Employed full-time Employed part-time Working and in school Other (Please specify):

4 Has Participant ever been a recipient of TANF or AFDC? YES NO Is Participant presently a TANF recipient? YES NO Is Participant currently receiving SSI or SSDI? YES NO Is Participant currently receiving Food Stamps? YES NO Will Participant be using direct deposit for their IDA? YES NO Monthly gross income of Participant household by source: $ Formal employment (before deductions) $ Self-employment (your own business, selling things you make, sewing, childcare, etc.) after deductions for business expenses $ Government assistance (TANF, Food Stamps, SSI, SSDI, Social Security, Unemployment Benefits, Veteran s Benefit, Worker s Comp) $ Pensions or retirement income $ Child support/alimony payments $ Investment income $ Rental Income $ Other (Please specify): Assets and Liabilities: Do you own a vehicle? Yes No If yes, value of vehicle: $ Loan amount on vehicle: $ Do you own a home? Yes No If yes, market value of home: $ Mortgage amount on home: $ Do you own a business? Yes No If yes, value of property: $ Loan amount for property: $ Do you own residential rental property or land? Yes No If yes, value of property: $ Loan amount for property: $ Do you own stocks, bonds, 401k or other investments? Yes No If yes, value of investments: $ Do you have a checking account? Yes No Amount in account: $ Do you have a savings account? Yes No Amount in account: $ (other than the IDA) Do you owe money to friends/family? Yes No If yes, amount: $ Do you have past due household bills? Yes No If yes, amount: $ Do you have past due household bills? Yes No If yes, amount: $ Do you have credit card debt? Yes No If yes, amount: $ Do you have past due credit card bills? Yes No If yes, amount: $ Do you have student loans? Yes No If yes, amount: $

5 Do you have past due student loan payments? Yes No If yes, amount: $ Do you have past due medical bills? Yes No If yes, amount: $ Do you have health insurance? Yes No If yes, amount: $ Do you have life insurance? Yes No If yes, amount: $ I verify that the above information is true to the best of my knowledge. Participant s Signature: Date:

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