Homeowners(s) Financial Information

List Dependents and other who live with you (not listed as a co-applicant)

Total Gross Monthly Household Income

Total Household Liquid Assets

PLEASE NOTE: Self-employed applicants may be required to provide additional documentation such as tax returns and financial statements.

To whom do you and the co-applicant owe money

Applicant’s Account

Co-Applicant’s Accounts

Homeowner Commitment Statement

This is a contract between the homeowner(s) and Habitat for Humanity of Washington County, AR Inc. In signing this application, the homeowner(s) are confirming that all information submitted is correct and truthful. The homeowner(s) acknowledge that Habitat has the authority to verify all information on the application and will run a credit check, OFAC, criminal background check, and sex offender check on all homeowner(s) and persons who reside in the home who are ages 18 and over. If the information submitted is found to be materially different than submitted, Habitat has the right to cancel this agreement at any time.

Disclosure and Authorization to Obtain a Consumer and Criminal Background Report

In connection with your anticipated or continued engagement as a potential Habitat for Humanity Repair Program participant, Habitat is hereby advising you that it will obtain or have prepared one or more consumer reports bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. Habitat for Humanity of Washington County, AR Inc. is henceforth known in this document as Habitat.

Such consumer reports, where applicable, would be obtained for the permissible purpose of legitimate business need in connection with your anticipated or continued engagement as a potential Repair Program recipient, in accordance with your written instruction. The scope of this notice is all-encompassing, allowing Habitat to obtain from any outside organization all manner of consumer reports now and throughout the course of your anticipated and continued engagement as a potential homeowner to the extent permitted by law.

This Disclosure is valid for current and future reports, and Habitat intends for this Disclosure to cover both your anticipated engagement as a potential Repair Program recipient, and any additional consumer reports obtained while you remain a part of the Repair Program.

Authorization To Obtain Consumer Reports

I hereby authorize Habitat to obtain or have prepared one or more consumer reports on me in connection with my anticipated or continued engagement as a potential Repair Program recipient, in accordance with my written instructions herein, and any other use not prohibited by law as applicable. These reports may contain information regarding my credit history, criminal record history, driving record history, and any other type of information that is permissible by all governing laws. I understand this information may be obtained from previous employers, companies, corporations, law enforcement agencies, persons, educational institutions, and other agencies, businesses, and individuals. I hereby authorize and direct all persons who may have information relevant to any such consumer report to disclose it to Habitat or its agents.

I acknowledge that Habitat has a legitimate business need to obtain my consumer and criminal background report, to verify eligibility for the Repair Program, to protect the safety and security of the premises in which homes might be built, to ensure the safety of vulnerable populations, including but not limited to, children, the elderly, and the indigent, and to protect the reputation of Habitat and the quality of services it provides.

This Authorization is valid for current and future reports, and I specifically understand that Habitat intends for this Authorization to cover both my anticipated engagement as a potential Habitat Repair Program Recipient up to the closing portion of that process and, any additional consumer reports obtained while I remain a part of the Repair Program.

Homeowner Survey

Additional Survey Information May Be obtained Depending on Funding Source

PLEASE READ THIS STATEMENT BEFORE COMPLETING THE SECTION BELOW:We are requesting the following information to monitor our compliance with the federal Equal Credit Opportunity Act, which prohibits unlawful discrimination. You are not required to provide this information. We will not take this information (or your decision not to provide this information) into account in connection with your application or credit transaction. The law provides that a creditor may not discriminate based on this information or based on whether or not you choose to provide it. If you choose not to provide the information, we may note it by visual observation or surname.

Applicant Information

Co-Applicant Information