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2. Do you have the following digital documents ready to upload? If not, please compile all the documents listed and have them ready for a later step in the application process. *

   1. Previous Tax Year Return
   2. Latest Employment Pay Stub / Public Assistance / Retirement
   3. Mortgage Statement Including Current Balance

   1. Homeowner's Insurance Statement
   2. Picture Identification
4. Address of the property to be rehabilitated*
6. Applicant Name*
7. Birth Date*
8. Will the be a Co-Applicant?*

   1. Yes
   2. No
10. Present Address*
11. How long have you lived at this address?*
13. Home Telephone*
14. Work Telephone
15. Email Address*
17. Previous Residence*
18. How long have you lived at this address?*
20. I own and occupy this home as my principal residence*

    1. Yes
    2. No
21. Marital Status*

    1. Married
    2. Unmarried
    3. Separated
22. Female head of household*

    1. Yes
    2. No
23. Disabled*

    1. Yes
    2. No
25. Current Employer*
26. Employer Address*
28. Position/Title*
29. How long with this employer?*
31. Previous Employer*
32. Previous Employer Address*
34. Position/Title*
35. How long with this employer?*
39. Co-Applicant Name*
40. Co-Applicant Birth Date*
42. Co-Applicant Present Address*
43. How long at this address?*
45. Co-Applicant Home Telephone*
46. Co-Applicant Work Telephone
47. Co-Applicant Email*
49. Co-Applicant Employer*
50. Co-Applicant Employer Address*
52. Co-Applicant Position/Title*
53. How long with this employer?*
55. Name, address, and phone number of person not living with you*
57. How many people reside in your household?*
59. Household composition (List the head of your household and all members who live in your home. Give the relationship, age, race and ethnicity of each family member to the head of household)
61. 1 - Head of Household's Full Name *
63. Age*
64. Race*
    -- Select One --American IndianAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther
65. Ethnicity*
    -- Select One --Hispanic or LatinoNot Hispanic or Latino
69. Household Member #2 - Full Name*
70. Relationship*
72. 2 - Age*
73. Race*
    -- Select One --American IndianAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther
74. Ethnicity*
    -- Select One --Hispanic or LatinoNot Hispanic or Latino
78. Household Member #3 - Full Name*
79. Relationship*
81. Age*
82. Race*
    -- Select One --American IndianAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther
83. Ethnicity*
    -- Select One --Hispanic or LatinoNot Hispanic or Latino
87. Household Member #4 - Full Name*
88. Relationship*
90. Age*
91. Race*
    -- Select One --American IndianAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther
92. Ethnicity*
    -- Select One --Hispanic or LatinoNot Hispanic or Latino
96. Household Member #5 - Full Name*
97. Relationship*
99. Age*
100. Race*
     -- Select One --American IndianAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther
101. Ethnicity*
     -- Select One --Hispanic or LatinoNot Hispanic or Latino
105. Household Member #6 - Full Name*
106. Relationship*
108. Age*
109. Race*
     -- Select One --American IndianAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther
110. Ethnicity*
     -- Select One --Hispanic or LatinoNot Hispanic or Latino
114. Household Member #7 - Full Name*
115. Relationship*
117. Age*
118. Race*
     -- Select One --American IndianAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther
119. Ethnicity*
     -- Select One --Hispanic or LatinoNot Hispanic or Latino
121. ANNUAL INCOME (List all income from all sources received by all household members 18 years old or older)
122. Number of Sources of Income*
124. Name of Household Member #1*
125. Source of Income*
126. Monthly Gross Income*
128. Name of Household Member #2*
129. Source of Income*
130. Monthly Gross Income*
132. Name of Household Member #3*
133. Source of Income*
134. Monthly Gross Income*
136. Name of Household Member #4*
137. Source of Income*
138. Monthly Gross Income*
140. Name of Household Member #5*
141. Source of Income*
142. Monthly Gross Income*
144. Name of Household Member #6*
145. Source of Income*
146. Monthly Gross Income*
148. Name of Household Member #7*
149. Source of Income*
150. Monthly Gross Income*
152. Total Household Gross Income*
154. Assets & Liabilities
156. Estimated Home Value*
157. Mortgage Balance*
159. LIABILITIES (List outstanding obligations (your debts) including auto loans, credit cards, charge accounts, credit union, bank loans, personal loans, real estate loans (except on the home you live in), and all other debts.)
161. Type of Debt, Creditor, Monthly Payment, Unpaid Balance, Due Date (press enter to add multiple debts)*
     If you have no monthly debts, comment above with "none"
163. Monthly Alimony*
     Enter $0 if not applicable
164. Monthly Child Support*
     Enter $0 if not applicable
165. Monthly Child Care*
     Enter $0 if not applicable
169. Do you have unpaid judgements?*

     1. Yes
     2. No
170. Have you declared bankruptcy in the past 7 years?*

     1. Yes
     2. No
171. Are you party in a current lawsuit?*

     1. Yes
     2. No
173. If you answer “Yes” to any of the questions above, explain below..
175. Mortgage Balance*
176. Monthly Payment*
177. Past Due Amount (if any)*
178. Real Estate Taxes*
180. Homeowner's Insurance Monthly Payment*
181. Balance of Other Financing Secured By Property
182. Monthly Payment (other financing)
183. Other (please specify)
185. Is there a balloon payment?*

     1. Yes
     2. No
186. Balloon Amount
187. Due Date
189. Describe any special circumstances relative to your housing or its financing:
191. Estimated Loan Amount
193. List below the exterior improvements you would like to do with the HELP loan. Refer to HELP guidelines for eligible work items:*
195. Applicant's Identification*
196. Co-Applicant's Identification
198. Pay Statements*
199. Latest Tax Filing Information*
201. Mortgage Statement*
202. Homeowner's Insurance*
204. Additional Document Upload
205. Additional File Upload
207. Additional File Upload
208. Additional File Upload
210. The information provided above is true and complete to the best of my/our knowledge and belief. I/We consent to the disclosure of such information for purposes of verification related to my/our application for financial assistance. I/We understand that any willful misstatements will be grounds for disqualification. I/We hereby acknowledge receipt of the Home Exterior Loan Program Guidelines and agree to comply with procedures and requirements specified therein. PENALTY FOR FALSE OR FRAUDULENT STATEMENT. U.S.C. Title 18, Sec 1001, provides: “Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies or makes any false, fictitious or fraudulent statements or representations, or makes or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years or both.”
212. Electronic Signature Agreement. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by the above terms and conditions.*

     1. I accept
214. Applicant's Digital Signature (Type)*
215. Today's Date*
     Today's Date
217. Co-Applicant's Digital Signature (Type)*
218. Today's Date*
     Today's Date
220. This is your authority to verify my bank accounts, employment, outstanding debts, including any present or previous mortgages, to order a consumer credit report, and to make any other inquiries pertaining to my qualifications for a mortgage loan from you. You may make copies of this letter for distribution to any party with which I have a financial or credit relationship and that party may treat such copy as an original. Privacy Act Notice: This information is to be used by the agency collecting it or its assignees in determining whether you qualify as a prospective mortgagor under its program. It will not be disclosed outside the agency except as required and permitted by law. You do not have to provide this information but if you do not your application for approval as a prospective mortgagor or borrower may be delayed or rejected.
222. Applicant's Digital Signature (Type)*
223. Today's Date*
     Today's Date
225. Co-Applicant's Digital Signature (Type)*
226. Today's Date*
     Today's Date
Leave This Blank:


228. 1. Receive an email copy of this form.
229. Email address

     This field is not part of the form submission.

230. Submit

* indicates a required field