Full Name: Property address: City: State: ZIP Code: Mailing address: City: State: ZIP Code: Own Rent How long? Monthly Housing payment: $ Cell: Home: Work: Date of birth: SSN: Email: Race (HUD requires clients to report all below Demographic Information): American Indian/Alaskan Native American Indian/Alaskan Native & Black Asian American Indian/Alaskan Native White & Black/African American Asian & White Native Hawaiian/Pacific Islander Black/African American & White White Other: Ethnicity (check one): Hispanic Not Hispanic Gender (check one): Female Male Other: Country of Origin: Preferred Language: Highest Education Completed (check highest): Less than High School Completion High School Diploma GED Diploma Vocational Certificate Degree Degree Associate’s Bachelor’s Degree Doctoral Degree Master’s Household Type (check one): Female Headed Single Parent Male Headed Single Parent Married with Dependents Married without Dependents Two or more unrelated adults Single Adult Other: Check all that apply Disabled US Veteran Household size: Number of Dependents: Estimated Household Monthly Income: Referred by: Internet Word of Mouth Government Bank Realtor Other: Privacy Policy Housing is committed to assuring the privacy of individuals and/or Initiative Partnership (“HIP”) families who have contacted us for assistance. We realize that the concerns you bring to us are highly
Full Name: Property address: City: State: ZIP Code: Mailing address: City: State: ZIP Code: Own Rent How long? Monthly Housing payment: $ Cell: Home: Work: Date of birth: SSN: Email: Race (HUD requires clients to report all below Demographic Information): American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Pacific Islander White American Indian/Alaskan Native & Black American Indian/Alaskan Native & White Asian & White Black/African American & White Other: Ethnicity (check one): Hispanic Not Hispanic Gender (check one): Female Male Other: Country of Origin: Preferred Language: Highest Education Completed (check highest): Less than High School Completion GED Diploma Associate’s Degree Master’s Degree High School Diploma Vocational Certificate Bachelor’s Degree Doctoral Degree Household Type (check one): Female Headed Single Parent Married with Dependents Two or more unrelated adults Other: Male Headed Single Parent Married without Dependents Single Adult Check all that apply Disabled US Veteran Household size: Number of Dependents: Estimated Household Monthly Income: Referred by: Internet Word of Mouth Government Bank Realtor Other: Privacy Policy Housing Initiative Partnership (“HIP”) is committed to assuring the privacy of individuals and/or families who have contacted us for assistance. We realize that the concerns you bring to us are highly
PrePurchaseIntakePackage.Final_.2016.docx