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2020 Pre-Qualification Questionnaire

Home / 2020 Pre-Qualification Questionnaire

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CONSENT TO RECEIVE ELECTRONIC DISCLOSURES UNDER THE ELECTRONIC SIGNATURES IN GLOBAL AND NATIONAL COMMERCE ACT (E-SIGN Act)

Please read this information carefully and print a copy and/or retain this information electronically for future reference. You are submitting a request for a pre-qualification, loan application, or referral form through Habitat for Humanity of Broward. Habitat for Humanity of Broward can provide you with some of the benefits of our services by conducting some of our business through the internet. This document informs you of your rights when receiving legally required disclosures, notices and information from Habitat for Humanity of Broward.

By completing and submitting your request through Habitat for Humanity of Broward, you acknowledge receipt of this document and consent to the electronic delivery of such disclosures, notices, documents and other pertinent information.

Electronic Communications Disclosures, notices and information related to this request will be provided to you electronically. However, if you wish to obtain a paper copy of any notice or disclosure, you may write to Habitat for Humanity of Broward at 3564 N. Ocean Blvd. Fort Lauderdale, Florida 33308 with the details of your request. Paper copies will be provided to you at no charge. You may withdraw your consent at any time by contacting us at Habitat for Humanity of Broward.

Joint Accounts If you are applying jointly with another person, either one of you may consent to receive or cancel electronic disclosures and notifications. Such consent shall apply to all owners.

System Requirements In order for you to access and retain your notifications and disclosures, your personal computer must have internet and email access.

Changes to your Contact Information You should keep us informed of any change in your electronic mailing address. Please notify us immediately of any changes to your email address or your system capabilities that enable you to receive electronic notification and disclosures.
Required*
- I Agree

Applicant Information
First Name*
Last Name*
Address*
Street Address City ZIP Code
Sorry. You must live in Broward County. Applicants outside of Broward will not be accepted.
Email*
Phone*
Occupation*
Employer/Company Name
Have you lived outside of Broward County during the last 12 months?*
- YES
- NO
Have you been unemployed or have had unverifiable income in the last 12 months or more?*
- YES
- NO
Have you filed for bankruptcy in the last 3 years?*
- YES
- NO
Have you ever owned a home or been on the deed for any property?*
- YES
- NO
Have you ever been convicted of a federal crime or any of the crimes listed below?*
(Sexual Misconduct, Disorderly conduct involving disturbance of neighbor; Criminal activity involving destruction of property; Two or more misdemeanor drug-related convictions related to manufacturing, delivery or sale; Any drug-related felony; Violent crimes including: murder, child abuse, sexual assault, battery, aggravated assault and assault with a deadly weapon.)
- YES
- NO
I am willing to make a commitment to the Habitat program, which requires that homeowner candidates earn sweat equity hours and attend a series of homeownership classes.*
- I Agree
Is there a co-applicant?*
- YES
- NO
Thank you for your interest in becoming a Habitat Homeowner. At this time, we regret that you are not eligible for this program.

Co-applicant Information
First Name*
Last Name*
Address*
Street Address City ZIP Code
Email
Phone*
Have you lived outside of Broward County during the last 12 months?*
- YES
- NO
Have you been unemployed or have had unverifiable income in the last 12 months or more?*
- YES
- NO
Have you filed for bankruptcy in the last 3 years?*
- YES
- NO
Have you ever owned a home or been on the deed for any property?*
- YES
- NO
Have you ever been convicted of a federal crime or any of the crimes listed below?*
(Sexual Misconduct, Disorderly conduct involving disturbance of neighbor; Criminal activity involving destruction of property; Two or more misdemeanor drug-related convictions related to manufacturing, delivery or sale; Any drug-related felony; Violent crimes including: murder, child abuse, sexual assault, battery, aggravated assault and assault with a deadly weapon.)
- YES
- NO
I am willing to make a commitment to the Habitat program, which requires that homeowner candidates earn sweat equity hours and attend a series of homeownership classes.*
- I Agree
Thank you for your interest in becoming a Habitat Homeowner. At this time, we regret that you are not eligible for this program.

Household Residents
Applicant Name:
Applicant First Name
Applicant Last Name
Co-Applicant Name:
Co-Applicant First Name
Co-Applicant Last Name
OLD NOT including the above-mentioned applicant(s), how many people would be living in the house?
Please enter a number from 1 to 9.
NOT including the above-mentioned applicant(s), how many people would be living in the house?*
Please enter a number from 0 to 9.
Name #1*
Age #1*
Gender #1*
Name #2*
Age #2*
Gender #2*
Name #3*
Age #3*
Gender #3*
Name #4*
Age #4*
Gender #4*
Name #5*
Age #5*
Gender #5*
Name #6*
Age #6*
Gender #6*
Name #7*
Age #7*
Gender #7*
Name #8*
Age #8*
Gender #8*
Name #9*
Age #9*
Gender #9*
Total Household Monthly Income
List the total monthly income of all applicants. Include income from these sources: Wages (before taxes and deductions), Social Security, alimony, child support, any other regular monthly income. Please list each different type of income along with the monthly amount:
Monthly Wages*
Please enter a number from 0 to 9999.
Calculated Annual Wages
Monthly Social Security*
Please enter a number from 0 to 9999.
Calculated Annual Social Security
Monthly Alimony*
Please enter a number from 0 to 9999.
Calculated Annual Alimony
Monthly Child Support*
Please enter a number from 0 to 9999.
Calculated Annual Child Support
Monthly Disability*
Please enter a number from 0 to 9999.
Calculated Annual Disability
Other Taxable Monthly Income*
Please enter a number from 0 to 9999.
Calculated Annual Other Income
Please Describe Other Taxable Income*
TOTAL MONTHLY INCOME
Total Household Monthly Expenses
List the total monthly expense of all applicants. Include expenses from these sources: credit cards, car payments, loans such as furniture or student loans, or any other debts (do not include utilities).
Monthly Rent Payment*
Please enter a number from 0 to 9999.
Calculated Annual Rent Payment
Monthly Alimony/Child Support Payment*
Please enter a number from 0 to 9999.
Calculated Annual Payments
Total Credit Card Debt*
Please enter a number from 0 to 99999.
Monthly Credit Card Payment*
Please enter a number from 0 to 9999.
Total Car Debt*
Please enter a number from 0 to 99999.
Monthly Car Payment*
Please enter a number from 0 to 9999.
Total Student Loan Debt*
Please enter a number from 0 to 99999.
Monthly Student Loan Payment*
Please enter a number from 0 to 99999.
Other Monthly Expenses*
Please enter a number from 0 to 99999.
Please Describe Other Expenses*
Other Monthly Loan Payments*
Please enter a number from 0 to 99999.
Please Specify Other Loans*
TOTAL MONTHLY EXPENSES
Do you have any unpaid debts that are in Collections?*
- YES
- NO
Medical Collection Amount*
Please enter a number from 0 to 99999.
Non-Medical Collection Amount*
Please enter a number from 0 to 99999.
By submitting this form, I/We affirm that the information on this form is true. I understand that providing false information could cause me/us to be disqualified from the Habitat program. I/We understand that a Habitat Associate will contact me (via the email submitted on this form) with the results from this questionnaire and that I/We may be invited to complete a homeowner application.
Applicant Full Name*
Applicant Signature*
Co-Applicant Full Name*
Co-Applicant Signature*
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.