BIENESTAR HOUSING RESOURCE CENTER A DIVISION OF COMITE DE BIEN ESTAR, INC.

Transcription

1 BIENESTAR HOUSING RESOURCE CENTER A DIVISION OF COMITE DE BIEN ESTAR, INC. 963 E. B STREET P.O. BOX 7170, SAN LUIS, AZ : (928) FAX: (928) GENERAL INTAKE FORM INTAKE FORM NUMBER: APPLICANT INFORMATION LAST FIRST DOB AGE SOCIAL SECURITY NUMBER STREET & P.O. BOX COUNSELOR : APARTMENT/UNIT # M.I. CITY STATE ZIP CODE ARE YOU A U.S. CITIZEN? ARE YOU A PERMANENT RESIDENT OF U.S.? WHAT IS YOUR CURRENT HOUSING SITUATION? ARE YOU CURRENTLY EMPLOYED? RENTING OWN LIVING WITH A FAMILY MEMBER LIVING IN MEXICO OTHER LEVEL OF EDUCATION ATTAINED PREFERRED LANGUAGE EDUCATION ELEMENTARY HIGH SCHOOL COLLEGE DID YOU GRADUATE? DEGREE DID YOU GRADUATE? DEGREE DID YOU GRADUATE? DEGREE BUSINESS/TRADE/TECHNICAL DID YOU GRADUATE? DEGREE

2 2 RACE RACE AND ETHNECITY WHITE BLACK OF AFRICAN DECENT ASIAN NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER ASIAN AND WHITE AMERICAN INDIAN/ALASKA NATIVE AMERICAN INDIAN OR ALASKA NATIVE AND WHITE BLACK OR AFRICAN AMERICAN AND WHITE AMERICAN INDIAN OR ALASKA NATIVE AND BLACK OR AFRICAN AMERICAN OTHER/MULTIPLE RACES I PREFER T PROVIDE THIS INFORMATION ETHNICITY HISPANIC N- HISPANIC MEXICAN OTHER HOUSEHOLD MEMBER INFORMATION EMPLOYMENT HISRY COMPANY FRO M MAY WE CONTACT YOUR PREVIOUS FOR A COMPANY FRO M MAY WE CONTACT YOUR PREVIOUS FOR A Comite De Bien Estar, Inc. strives to enhance the 2 economic and social well-being of the community

3 3 CO-APPLICANT INFORMATION Last Name First M.I. Date of Birth Age Social Security Number Street Address & P.O. BOX Apartment/Unit # City State ZIP Code Phone Address Are you a U.S. citizen? Are you a permanent resident of U.S.? What is your current housing situation? Renting Own Living with a family member Living in Mexico Other Are you currently employed? Level of education attained Preferred language EDUCATION Elementary High School College To Did you graduate? Degree To Did you graduate? Degree To Did you graduate? Degree Business/Trade/Technical Course of Study To Did you graduate? Degree Race RACE AND ETHNECITY White Black of African Decent Asian Native Hawaiian or Other Pacific Islander Asian and White American Indian/Alaska Native American Indian or Alaska Native and White Black or African American and White American Indian or Alaska Native and Black or African American Other/Multiple Races I prefer not to provide this information Ethnicity Hispanic Non- Hispanic Mexican Other Comite De Bien Estar, Inc. strives to enhance the 3 economic and social well-being of the community

4 4 HOUSEHOLD MEMBER INFORMATION EMPLOYMENT HISRY COMPANY MAY WE CONTACT YOUR PREVIOUS FOR A COMPANY MAY WE CONTACT YOUR PREVIOUS FOR A GROUP COUNSELING DATE: PROPERTY SERVICES. HOURS GROUP COUNSELING: OF INDIVIDUAL COUNSELING HOURS: P.O. BOX CITY STATE ZIP CODE TYPE OF SERVICE: DEBT AND MONEY MANAGEMENT COUNSELING SELF HELP PROGRAM FORECLOSURE PREVENTION ASSISTANCE PRE PURCHASE DOWN PAYMENT ASSISTANCE (AHP) DOL IDA OTHER HAVE YOUR RECEIVED RENTAL OR UTILITY ASSISTANCE ATHER AGENCY? IF YOU HAVE RECEIVED UTILITY ASSISTANCE ATHER AGENCY, PLEASE STATE THE Comite De Bien Estar, Inc. strives to enhance the 4 economic and social well-being of the community

5 5 CONFLICT OF INTEREST STATEMENT TE APPLICANTS: THE FOLLOWING COUNSELING SERVICES; FIRST TIME HOME BUYERS, DEBT CONSOLIDATION MANAGEMENT, COUNSELING/LOANS, FINANCIAL LITERACY CLASS, DOWN PAYMENT ASSISTANCE, FORECLOSURE PREVENTION ASSISTANCE PROGRAM/NFMC, SELF-HELP PROGRAM, MICRO BUSINESS LOANS, HOME REPAIR LOAN, VEHICLE LOAN, EDUCATION LOANS, HOME CONSTRUCTION, LAND DEVELOPMENT, TRANSPORTATION PROGRAM AND OTHER SOCIAL AND CULTURAL PROGRAMS OFFERED BY COMITE DE BIEN ESTAR, INC. AND ITS SUBSIDIARIES, AFFILIATES OR DIRECRS, OFFICERS, EMPLOYEES, AGENTS OR PARTNERS MAY ALSO BE OFFERED BY OTHER PROVIDERS AND YOU ARE UNDER OBLIGATION REQUEST OR UTILIZE SERVICES PROVIDED BY COMITE DE BIEN ESTAR, INC. COMITE DE BIEN ESTAR, INC. HAS FINANCIAL AFFILIATION WITH HUD, RCAC, BORDER FINANCIAL RESOURCES, NATIONAL BANK, BANK OF AMERICA, NEIGHBORWORKS AMERICA, AND THE NATIONAL COUNCIL OF LA, WHOM ARE AN INDUSTRY PARTNER. IF ANY INFORMATION ON THIS APPLICATION IS FOUND BE FALSE OR INCOMPLETE, SUCH FINDING, IN ADDITION POSSIBLE LIABILITY UNDER CIVIL AND CRIMINAL COURT, MAY ALSO BE CONSIDERED GROUNDS FOR DENIAL OF THE REQUESTED CREDIT AND MAY BE BASIS FOR DEBARMENT PARTICIPANT IN ALL FEDERAL PROGRAMS UNDER STATUTE 7 C.F.R. PART 3017 CERTIFICATION: IF AWARDED ASSISTANCE PURCHASE A HOME, I (WE) WILL OCCUPY THE PROPERTY AS MY (OUR) PRINCIPAL PLACE OF RESIDENCE. SIGNATURES I AUTHORIZE THE VERIFICATION OF THE INFORMATION PROVIDED ON THIS FORM AS MY PERSONAL INFORMATION REGARDING MY SELF, FAMILY, INCOME, CREDIT AND EMPLOYMENT. I HAVE RECEIVED A COPY OF THIS APPLICATION. SIGNATURE OF APPLICANT: SIGNATURE OF CO-APPLICANT: DATE: DATE: Comite De Bien Estar, Inc. strives to enhance the 5 economic and social well-being of the community