The Amos Network of Lafayette County

First Time Homebuyer Education Program

Registration Form

(All information is confidential)

DATE:

APPLICANT INFORMATION:

LAST NAME: FIRST NAME: MIDDLE NAME:

DOB: SOCIAL SECURITY NUMBER:

MARTIAL STATUS (Please circle) SINGLE MARRIED DIVORCED SEPARATED WIDOWED

U.S. CITIZEN: YES NO

STREET ADDRESS:

CITY: STATE: ZIP: COUNTY:

HOME PHONE: ALTERNATE PHONE:

BEST TIME AND PLACE TO CONTACT YOU:

LENGTH OF RESIDENCY: YRS. MONTHS DO YOU OWN RENT OTHER

AVERAGE MONTHLY HOUSING EXPENSE: (Rent) CURRENT ADDRESS (Y/N)

PREVIOUS ADDRESS (IF LESS THAN 2 YEARS)

CITY: STATE: ZIP: COUNTY:

LENGTH OF RESIDENCY: YRS. MONTHS

CHECK ALL THAT APPLY:

US VETERAN FIRST TIME BUYER

SINGLE HEAD OF HOUSEHOLD PRIOR BUYER EDUCATION

OWNED HOME IN LAST 3 YEARS CURRENTLY RECEIVING RENTAL ASSISTANCE

RENTING LIVING WITH FAMILY MEMBER AND NOT PAYING RENT

RACE (Please circle the following items that apply)

1. White 6. American Indian/Alaskan Native and white

2. Black or African American 7. Asian and White

3. American Indian/Alaskan Native 8. Black/African American and White

4. Asian 9. American Indian/Alaskan Native and Black

5. Native Hawaiian/other Pacific Islander 10. Other

ETHNICITY: ARE YOU OF HISPANIC ORGIN: YES NO

CO-APPLICANT Name: DOB:

STREET ADDRESS:

CITY: STATE: ZIP: COUNTY:

HOME PHONE: ALTERNATE PHONE:

BEST TIME AND PLACE TO CONTACT YOU:

LENGTH OF RESIDENCY: YRS. MONTHS DO YOU OWN RENT OTHER

AVERAGE MONTHLY HOUSING EXPENSE: (Rent) CURRENT ADDRESS (Y/N)

PREVIOUS ADDRESS (IF LESS THAN 2 YEARS)

CITY: STATE: ZIP: COUNTY:

LENGTH OF RESIDENCY: YRS. MONTHS

Dependents Name: Age Relationship

_____________________________ ______ ________________________________

_____________________________ ______ ________________________________

_____________________________ ______ ________________________________

_____________________________ ______ ________________________________

_____________________________ ______ ________________________________

_____________________________ ______ ________________________________

_____________________________ ______ ________________________________

LANDLORD INFORMATION:

NAME: PHONE#: FAX#:

STREET:

CITY: STATE: ZIP: COUNTY:

EMPLOYMENT INFORMATION:

APPLICANT:

EMPLOYER NAME: PHONE: FAX#

ADDRESS:

CITY: STATE: ZIP: COUNTY:

POSITION/TITLE: HOURS PER WEEK: INCOME: Hr./Wk/BiwK/Mth/Ann.

Circle One

LENGTH OF EMPLOYMENT: YRS MO CURRENT JOB? SELF EMPLYOYED?

START DATE: END DATE:

PHONE#: FAX#:

PREVIOUS EMPLOYER NAME & ADDRESS (IF LESS THAN 2 YEARS):

EMPLOYMENT INFORMATION:

CO-APPLICANT:

EMPLOYER NAME: PHONE: FAX#

ADDRESS:

CITY: STATE: ZIP: COUNTY:

POSITION/TITLE: HOURS PER WEEK: INCOME: Hr./Wk/BiwK/Mth/Ann.

Circle One

LENGTH OF EMPLOYMENT: YRS MO CURRENT JOB? SELF EMPLYOYED?

START DATE: END DATE:

PHONE#: FAX#:

PREVIOUS EMPLOYER NAME & ADDRESS (IF LESS THAN 2 YEARS):

ADDITIONAL INCOME (CHILD SUPPORT, ALIMONY, ETC…):

TYPE OF INCOME: MONTHLY AMOUNT:

LIABILITIES (LOANS, CREDIT CARDS, ETC…):

ACCOUNT CURRENT MONTHLY PAYMENTS JOINT

DESCRIPTION NUMBER: BALANCE: PAYMENT: REMAINING: LIABILITY:

NON TRADITIONAL CREDIT (UTILITIES, ETC…):

MONTHLY LENGTH OF

DESCRIPTION PAYMENT: CREDIT: START: END:

AVAILABLE FUNDS (CHEKCING ACCOUNT, SAVINGS ACCOUNT, ETC…):

ACCOUNT TOTAL ASSET FUNDS JOINT

DESCRIPTION NUMBER: VALUE: AVAILABLE: ASSET:

• Have you ever filed for Bankruptcy? _________ (yes/no)
• If yes, then when? _______________
• What bankruptcy type was it? ________ (Chapter 7 or Chapter 13)
• When was it discharged? ________
• Do you have any judgements against you? _______________ (yes/no)
• If yes, when? _____________ How many? ______________
• How did you hear about us? (check all that apply)

□ Flyer □ Referred by Lender: ___________________________

□ Newspaper □ Referred by Real Estate Agent: __________________

□ Our Website □ Radio Station

□ Word of Mouth □ Employer

□ Email □ Other _______________________________________

ADDITIONAL SPACE/COMMENTS:

Applicant Signature Date Applicant Signature Date