Please fill out this brief application to assist with our selection process. If you do not
know or understand what is being requested, you may want to ask someone to assist you.
Call ________________ at ______________
if you need assistance in completing this application or have any other questions.
Name _________________________________________________________________________
Address_________________________________________________________________________
City __________________________
State_______________________ Zip______________
Telephone
(_____)_______________________
Do you have a disability? ______ Yes ______ No If yes, please describe your disability.
_______________________________________________________________________________
______________________________________________________________________________
Where would you like to live (ie: city, town, area)?
_____________________________________________________________________________
What type of home do you want to buy? (ie: ranch, 2 story, condominium, etc.)
_____________________________________________________________________________
Will you be purchasing this house yourself?
_____ Yes _____ No
If you will be purchasing your home with another individual, please describe
the relationship you have to this individual (i.e.: husband, wife, boyfriend, girlfriend, etc.)
_______________________________________________________________________________
_______________________________________________________________________________
Do you want to have a roommate(s)? ____ Yes
_____ No
Will a roommate(s) be paying rent?
____ Yes _____ No
Will your roommate(s) provide you with assistance?
_____ Yes ____ No
Please describe __________________________________________________________________
________________________________________________________________________________
Where are you currently living?
____ In a State Institution _____ In someone else's home
(Adult Foster Care)
____ In a Nursing Home
____ In a Group Home _____ Own Apartment
____ With my Family _____ Other Place (Please describe)
_____________________________________________________________________________
Do you currently use Personal Assistance Services? (Personal Assistant Services refers
to using an individual to assist with such things as getting in/out of bed, dressing,
cooking meals, getting to/from places and other tasks)
____Yes ____No
Do you currently use a Section 8 certificate or voucher? _____ Yes ____ No
Do you have any credit problems that you know about? ____ Yes ____ No
Please fill out the budget form below, listing all your monthly income and expenses.
If there is more than one person purchasing (i.e., married couple), list monthly income
and expenses separately. Please fill out a separate budget form for each individual.
Income from Employment Monthly
__________________________ _____
__________________________
_____
Total
$_____
Benefit Income
SSI
_____
SSDI
_____
Aid to Dependent Children
_____
Food Stamps
_____
Home & Community Based Waiver
_____
Other
_____
Subtotal
$_____
Other Income Subtotal
$_____
Income Grand Total Total
$_____
Housing
Monthly
Rent
_____
Electric/Gas
_____
Water
_____
Telephone
_____
Other
_____
Subtotal
$_____
Food Subtotal $
Cleaning Supplies
Subtotal $_____
Clothing Subtotal $_____
Automobile
Loan
Gas & Oil _____
Insurance
_____
Maintenance/Repair
_____
Transportation
_____
Subtotal $
Debts
Credit Cards
Loans _____
Other _____
Subtotal $_____
Medical
Medication (co-pay)
Medical/Dental _____
Personal Assistance Services _____
Other _____
Subtotal $_____
Entertainment
Cable TV
Newspaper _____
Subtotal $
Other Subtotal $_____
Expenses Grand Total