Part 1 : Intake Form Applicant Name * First Name Last Name Date MM DD YYYY Co-Applicant Name * First Name Last Name Relationship to Applicant * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Habitat Affiliate * Yes No Email Address * Phone Number * (###) ### #### Other Contact Number (###) ### #### Household Information Household Member 1 (Head of Household) * First Name Last Name Race of Head of Household * American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Pacific Islander White Choose not to respond. Household Member 1 Date of Birth * MM DD YYYY Household Member 1 Social Security Number * Household Member 1 Gender * Male Female Hispanic * Yes No Household Member 2 (Co-Head of Household) * First Name Last Name Race of Co-Head of Household * American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Pacific Islander White Choose not to respond. Household Member 2 Date of Birth * MM DD YYYY Household Member 2 Social Security Number * Household Member 2 Gender * Male Female Hispanic * Yes No Household Member 3 First Name Last Name Household Member 3 Date of Birth MM DD YYYY Household Member 3 Social Security Number Household Member 3 Gender Male Female Hispanic Yes No Household Member 4 First Name Last Name Household Member 4 Date of Birth MM DD YYYY Household Member 4 Social Security Number Household Member 4 Gender Male Female Hispanic Yes No Additional Household Members Please add additional household members in this area. Additionally, please make sure to include their Name, Date of Birth, Social Security Number, Gender, and if they are Hispanic. rental information Do you rent or own? * Yes No If yes, how much is your monthly payment? Current income sources Is employment a current income source? * Yes No If yes, what is the amount? Is SSI a current income source? * Yes No If yes, what is the amount? Is FIP a current income source? * Yes No If yes, what is the amount? Are food stamps a current source of income? * Yes No If yes, what is the amount? Is Unemployment a current income source? Yes No If yes, what is the amount? Is being a Veteran a current income source? * Yes No If yes, what is the amount? Is Child Support a current income source? * Yes No If yes, what is the amount? If you have another current income source, please list it here. Please include the amount. Employment Place of Employment * Job Title * Hours * Pay Rate * Employer Phone Number * (###) ### #### Education For statistical purposes only. High School Diploma/GED? * Yes No Any additional education or vocational training? * Yes No If yes, please state what your education or vocational is and when date completed. Applicant Name * This will be used as the electronic signature. First Name Last Name Co-Applicant Name * This will be used as the electronic signature. First Name Last Name Todays Date * MM DD YYYY Authorization & Release I understand that by electronically signing this consent form, I am authorizing Habitat for Humanity of Michigan (HFHM), its agents, employee or Habitat Affiliates to request income and asset information from all income providers (ie, Social Security Administration, Employers, DHHS, etc), those entities listed on your intake form and any other related application forms (ie, local Habitat Affiliate application form, etc). Information may also be gathered from current or previous landlords if you are pursuing home ownership with Habitat. We may also receive information from credit reporting agencies, collection agencies and personal references for the purpose of program qualification and assistance. Further, you are allowing Habitat for Humanity of Michigan to provide this information to its agents, employees, or Affiliates involved with the Financial Coaching Network for the purposes in this program. The agents, employees, or Affiliates involved with HFHM Financial Coaching Network may also provide information to HFHM. We will also collect your information and outcomes of your efforts to provide to funders who support this program. Private companies (collection companies, etc) may not receive your personal information authorized by this form unless disclosure of such information is required under State or Federal Law. Confidentiality is important to us and we will always protect your privacy. * Applicant's Electronic Signature First Name Last Name Co-Applicant's Electronic Signature * First Name Last Name Today's Date * MM DD YYYY Part 2: Monthly household budget Net (after Taxes) Income Applicant Income * $ Co-Applicant Income * $ Social Security/SSI/Disability * $ Child Support * $ Food Stamps/FIA Income * $ Other Income * $ Total Monthly Income * Fixed Expenses Housing - Rent/Mortgage * $ Homeowner Association Fees * $ Line of Credit/Jr Liens * $ Car Loan * $ Car & Renters Insurance * $ Student Loans * $ Personal Loan/Line of Credit * $ Child Support * $ Child Care Expenses * $ Savings * $ Other Fixed Expenses * $ Total Fixed Expenses * Flexible Expenses Food - Groceries * $ Inbetween Grocery Expenses * $ Toiletries/Cosmetics * $ Natural Gas/Propane * $ Electric * $ Trash Removal * $ Water Bill * $ Telephone * $ Cell Phone * $ Automobile Gas * $ Automobile Maintainence * $ Cable/Internet * $ Movie Rentals * $ Laundry/Dry Cleaning * $ Activities/Going Out * $ Dinners Out * $ Lunches Out * $ Kids School Lunches * $ Dues/Subscriptions * $ Medical Insurance * $ Money Orders or Cashiers Checks * $ Banking Fees (ATM, Check Cashing, NSF) * $ Rent to Own/Payday Loans * $ Hair Care * $ Nail Care * $ Clothing * $ Cigarettes * $ Charity/Tithing * $ Education * $ Pets * $ Allowance/Children Activities * $ Other Flexible Expenses * $ Total Flexible Expenses Please add amounts from the Flexible Expenses Section. Occasional Expenses Property Taxes (if not included in Mortgage) * $ Homeowners Insurance (if not included in Mortgage) * $ Medical * $ Dental * $ Vision * $ Ongoing Medical * $ Birthdays * $ Christmas/Holidays * $ Vacation * $ Total Occasional Expenses * Please add amounts from the Occasional Expenses Section. $ Debt Reducing Expenses Debt Reducing Items * Please list all Debt Reducing items and their amount. Total Debt Reducing Expenses * $ Final calculations Total Monthly IncomeTot * $ Total Monthly Expenses * $ Difference - Gain/(Loss) * $ Signatures Applicant Name * This will serve as your Electronic Signature First Name Last Name Co-Applicant Name * This will serve as your Electronic Signature. First Name Last Name Thank you!
