Intake Housing Must complete before appointment date. Applicant’s Last Name*Applicant’s First Name/Middle Initial*Is English your preferred language?* Yes No Please call The HomeOwnership Center if you would like assistance in completing the application. Translation services are available. 937-853-1600Current Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* I authorize the HomeOwnership Center to pull a credit report, at no cost, to determine eligibility for funding opportunties.YesNoApplicant’s Social Security Number*This will only be used to pull your credit report.How did you hear about our the HomeOwnership Center?*LenderSocial MediaFriends/FamilyCityWideChurchOhio Housing Finance AgencyOtherGender* Female Male Other Applicant’s Date of Birth*Does someone in the household have a disability?* Applicant Co-Applicant Dependent No one in household has a disability Applicant Education Level* 0-8 9-12 (non-grad) HS Grad/GED Post-Secondary (non-grad) Associate/Bachelor's Degree Graduate Degree Marital Status* Married Not Married Applicant Military Status* Veteran Active Military N/A Is Applicant a U.S. Citizen?* Yes No Is there a co-applicant?* Yes No Co-Applicant’s Last Name*Co-Applicant’s First Name/Middle Initial*Co-Applicant’s Relationship to Applicant?*Co Applicant Current Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Co-Applicant Phone*Co-Applicant Email* Co-Applicant’s Social Security Number*Co-Applicant Gender* Female Male Other Co-Applicant’s Date of Birth*Co-Applicant Education* 0-8 9-12 (non-grad) HS Grad/GED Post-Secondary (non-grad) Associate/Bachelor's Degree Graduate Degree Co-Applicant Military Status* Veteran Active Military N/A Is Co-Applicant a U.S. Citizen?* Yes No How many people are in your household?*List all household members not already listed as Applicant and Co-Applicant.Last NameFirst Name, Middle InitialRelationship to ApplicantDate of BirthRaceEthnicity Household Income InformationPlease list all current employment for the applicant and co-applicant*EmployerStart DateWhose Job# of Hrs/WeekGross Annual Income Does ANYONE in your household receive non employment income (ex. Child Support, Social Security, Unemployment, Worker's Compensation, Veteran's Benefits, Pension, Other)?Income TypeWho Receives?AmountWeekly, Monthly, Annually? Information for Government Monitoring PurposesThe following information is requested by the federal government in order to monitor compliance with federal statutes that prohibit discrimination in housing. You are not required to furnish this information but are encouraged to do so. The law provides that a lender or servicer may not discriminate either on the basiss of this information, or on whether you choose to furnish it. If you furnish the information, please provide both ethnicity and race. For race you may check more than one sesignation. If you do not furnish ethniciy, race or sex, the lender or servicer is required to note the information on the basis of visual observation or surname if you have made this request in person. If you do not wish to furnish the information, select choose not to answer in drop down options.Applicant's Race*Choose Not to RespondAmerican Indian or Alaska NativeBlack or African AmericanWhiteAsianNative Hawaiian/Pacific IslanderMulitipleChoose not to answerApplicant's Ethnicity*Choose not to answerHispanic or LatinoNot Hispanic or LatinoCo-Applicant's RaceAmerican Indian or Alaska NativeBlack or African AmericanWhiteAsianNative Hawaiian/Pacific IslanderMulitipleChoose not to answerCo-Applicant's EthnicityHispanic or LatinoNot Hispanic or LatinoChoose not to answerSignature(s)Applicant Signature*Co-Applicant Signature* Upon submission, you will be asked to sign 4 additional forms listed below: Waiver and Authorization Privacy Policy Disclosure Importance of a Home Inspection (Disregard if not buying a home)
