Shippensburg Non

Print out the following forms to be included w/application (click on link to view & print):

Employment Verification

Guidelines

Shippensburg Non-Profit Housing Corporation

LUTHERAN HILL REVITALIZATION PROGRAM APPLICATION

To be considered for this program this application must be completed in full and the following documentation must accompany this application. Information must be provided for all persons who will be residing in the household.

copies of birth certificates for all persons residing in the household

copies of social security cards for all persons residing in the household

copies of w-2 forms and the most recent income tax return for all persons residing in the household and copies of most recent pay stubs for all persons residing in the household

copies of documentation showing public assistance, child support payments, unemployment benefits, pensions and annuities, Social Security award or benefit letter

1. GENERAL INFORMATION

Head of Household First, Middle, Last, (maiden) Name:

_____________________________________________________

Social Security Number: _____________________________________________________

Date of Birth: __________________________________________

Marital Status: ____ Married ___Separated ___Divorced ___Single

Telephone: Day: ________________________________________

Evening: _____________________________________

Present Address: _____________________________________________________

_____________________________________________________

How long at this address? _________________________________

Currently, I ____rent, ____live with family or friends, ____own my home

Name and address of landlord: ______________________________

______________________________________________________

List former addresses (last two years):

1. ____________________________________________

2. ____________________________________________

List names and address of former landlords (last two years):

_______________________________________

_______________________________________

_______________________________________

_______________________________________

Spouse or co-applicant's First , Middle, Last, (maiden) Name: ____________________________________________

Social Security Number: ___________________________________

Date of Birth: ___________________________________________

Telephone: Day: ___________________ Evening: _______________

Marital Status: ____ Married ___Separated ___Divorced ___Single

Present Address: _________________________________________

______________________________________________________

How long at this address? __________________________________

Currently, I____ rent, ____ live with family or friends, ____ own my home

Name and address of landlord: _______________________________

_______________________________________________________

List former addresses (last two years):

1. _____________________________________________

2. _____________________________________________

List names and address of former landlord (last five years):

________________________________________

________________________________________

________________________________________

________________________________________

C. Dependents Living In The Household:

Names(s) Birth Dates(s) Relationship

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

2. EMPLOYMENT HISTORY FOR HEAD OF HOUSEHOLD

A. Present employer: Name: __________________________________

Address: _________________________________________________

________________________________________________________

Your job title:_____________________________________________

How long employed? __________________________

Number of Hours Per Week: ___________________

B. Additional employment, please specify: __________________________________

_______________________________________________

Within the last 12 months, were you employed any place else? _______________

If yes, where? _______________________________________________

3. EMPLOYMENT HISTORY FOR SPOUSE or CO-APPLICANT

A. Present employer: Name: ____________________________________

Address: ___________________________________________________

__________________________________________________________

Your job title:_______________________________________________

How long employed? __________________________

Number of Hours Per Week: ___________________

B. Additional employment, please specify: ________________________________________________

________________________________________________

C. Within the last 12 months, were you employed any place else? _____________

If yes, where? ________________________________________________

4. FINANCIAL HISTORY

       A.     Household GROSS MONTHLY INCOME

                                                    Head of Household        Spouse or co-applicant

                ITEM

                Salary/Wages                $_____________        $__________________

                Dividends/Interest          $_____________        $__________________

                Pension                          $_____________        $__________________

                Social Security               $_____________        $__________________

                Alimony/Child Support   $_____________        $__________________

                Other Income                 $_____________        $__________________

        B.    CURRENT ASSETS

                Description                                                        Cash or Fair Market Value

                Checking Account                                             $____________________

                   Name of Bank ______________________

                  Address ___________________________

                  __________________________________

               Savings Account                                                $_____________________

                    Name of Bank _____________________

                    Address __________________________

                    _________________________________

                Additional Accounts ___________________

                ___________________________________

                ___________________________________    $____________________

                Life Insurance (Cash Value Only)                        $____________________

                Automobiles (Value of)                                        $____________________

                    Make: ___________________________

                    Year: ____________________________       $____________________

                    Make:____________________________

                    Year:_____________________________       $____________________

                TOTAL ASSETS                                                  $____________________

    C.    MONTHLY BUDGET: Approximate as close as possible.

Rent $ ____________ Heat $ ______________ Electric $ ____________

Gas $ _____________ Sewer $ _____________ Trash $ _____________

Water $ ___________ Phone $ _____________ Food $ ______________

Medical $ __________ Car Payment $ _________ Insurance$__________

Misc. $ ____________ Loans $ _____________ Other $ _____________

          $ ____________           $ _____________           $ _____________

          $ ____________           $ _____________            $ _____________

Student Loans Payments $_______________________________________

D.    CURRENT LIABILITIES

Creditor's Names & Addresses

                                                                                                    Minimum

                                                    Account                  Current    Monthly

Charge Accounts                         Number                 Balance     Payments

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Automobile Loans

__________________________________________________________________

__________________________________________________________________

Other Loans

__________________________________________________________________

__________________________________________________________________

Alimony & Child Support which you must pay monthly

__________________________________________________________________

__________________________________________________________________

TOTAL MONTHLY LIABILITIES:_______________________________________________________

C. Monthly Budget: Approximate as close as possible.

Rent $ ____________ Heat $ ______________ Electric $ ____________

Gas $ _____________ Sewer $ _____________ Trash $ _____________

Water $ ___________ Phone $ _____________ Food $ ______________

Medical $ __________ Car Payment $ _________ Insurance$_____________

Misc. $ ____________ Loans $ _____________ Other $ _____________

$ ____________ $ _____________ $ _____________

$ ____________ $ _____________ $ _____________

Student Loans Payments $________________________

D. CURRENT LIABILITIES

Creditor's Names & Addresses

                                                                                                           Minimum

                                                           Account         Current                Monthly

Charge                     Accounts             Number         Balance               Payments

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Automobile Loans

__________________________________________________________________

__________________________________________________________________

Other Loans

__________________________________________________________________

__________________________________________________________________

Alimony & Child Support which you must pay monthly

__________________________________________________________________

__________________________________________________________________

TOTAL MONTHLY LIABILITIES:_______________________________________________________

All applicants, please answer the following. If a "yes" is given to a question, explain on an attached sheet of paper.

Have you any outstanding judgments?

___ Yes    ____ No

In the last 7 years have you been declared bankrupt? ____ Yes   ____ No

If yes, bankruptcy was discharged on __________________________________.

Have you had property foreclosed upon? ____ Yes ____ No

or given title or deed in lieu thereof?

____ Yes ____No

Are you a co-signer or endorser on a note? ____ Yes    ____ No

Are you a party in a law suit?

____ Yes    ____ No

Have you ever been convicted of a crime? ____ Yes    ____ No

If convicted of a crime, state date and circumstances._____________________________________________________

_________________________________________________________________

Have you ever been an owner or co-owner of real-estate: ___Yes   ___No

If yes, when?____________________________

If yes, did you own the real-estate with a spouse from a previous marriage?

__ __Yes __ __No

Complete the following:

Are you a U.S. citizen ___ ___ Yes ___ ___No

Are you a permanent resident alien ____ ____Yes ___ ___ No

If you are not a U.S. citizen, documentation regarding your immigration status must be provided with this application.

I FULLY UNDERSTAND IT IS A FEDERAL CRIME PUNISHABLE BY FINE OR IMPRISONMENT, OR BOTH, TO KNOWINGLY MAKE ANY FALSE STATEMENTS CONCERNING ANY OF THE ABOVE FACTS AS APPLICABLE UNDER THE PROVISIONS OF TITLE 18, UNITED STATES, SECTION 1014.

______________________________            _____________________

Signature                                        Date

______________________            _______________

Signature                                          Date

FIRST TIME HOMEBUYER STATUS CERTIFICATION

I/ We hereby certify that I/we am/are first-time homebuyer(s)* or that I/we have not owned a home within the last three years.

______________________            _______________

Signature                                          Date

______________________            _______________

Signature                                          Date

A first-time homebuyer is defined as someone who has never before owned a home, has owned a mobile home but not the land the mobile home was located on, or someone who has lost their home due to a divorce settlement and has not owned a home since (displaced homemaker).

GENERAL RELEASE OF INFORMATION

Date __________________________________

I/We, the undersigned, give the Housing and Redevelopment Authorities of the County of Cumberland written permission to obtain verification of information from any source given in this application including obtaining a credit report. This information is to be used to determine eligibility for participation in the Lutheran Hill Revitalization Program.

_______________________ _________________________

Witness Applicant

_______________________ _________________________

Witness Applicant

The following two pages are Employment Verification Forms. Each working applicant must complete the top portion of the form. You are permitted to make copies of these forms if either applicant has more than one job. The verifications with the completed top portion only must be included with the application.

I would like the requested information regarding my wages furnished to the Redevelopment Authority of the County of Cumberland as soon as possible.

______________________ _______________

Signature Date

THANK YOU FOR YOUR COOPERATION IN SUPPLYING THIS INFORMATION

Attn: Pat Mrkobrad Housing Programs Manager

Cumberland County Redevelopment Authority

114 North Hanover Street, Carlisle, PA 17013

Tel. 717-249-0789

Please feel free to fax this information to Pat at fax number 717-249-4071

INFORMATION FOR GOVERNMENT MONITORING PURPOSES

The following information is requested by the Federal Government for certain types of home ownership and housing rehabilitation programs. You are not required to furnish this information, but are encouraged to do so. However, if you choose not to furnish it, under Federal regulations this Authority is required to note race and ethnicity and gender on the basis of visual observation or surname.

Applicant #1

Ethnicity: Are you Hispanic or Latino? __ yes __no

Race : __ American Indian or Alaskan native

__ Black/African American

__ Asian

__ Native Hawaiian/other Pacific Islander

__ White

Gender: __ Female __ Male

__ I do not wish to furnish this information.

Applicant #2

Ethnicity: Are you Hispanic or Latino? __ yes __no

Race: __ American Indian or Alaskan native

__ Black/African American

__ Asian

__ Native Hawaiian/other Pacific Islander

__ White

Gender: __ Female __ Male

__ I do not wish to furnish this information.

Please list ethnicity, race, and gender of all other household members.

NUMBER OF ADDITIONAL MEMBERS IN HOUSEHOLD: ___________

Please identify each household member by: ethnicity: Hispanic or Latino or NOT Hispanic or Latino; race: (use 1 of 5 categories shown above); and gender.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

__ I do not wish to furnish this information.