DISTRICT 6 H.R.D.C.

FIRST TIME HOME BUYER PROGRAM

300 1^ST. AVE. N. STE. 203

LEWISTOWN, MT 59457

APPLICATION QUESTIONNAIRE

The following form is designed to help in determining if you may be eligible to participate in the District 6 HRDC First Time Home Buyer Program, to qualify for the Montana Board of Housing mortgage loan, and/or to receive grant money for down payment and closing cost assistance.

Please list all members of the household who reside with you on a full time basis (use extra paper if necessary):

	Last Name	First Name	M I	Social Security Number	Relationship To Applicant	Birthdate Mo-Day-Yr
HH
2
3
4
5
6

Current mailing address Street Address (if different)

____________________________________________________________________________________________________________

City State Zip How many years at Current Address

Home Phone ___________________ Work or Message Phone_________________________________________________________

Are any family members disabled? Yes No (circle one) If yes, who_________________________________Type

of Disability____________________________________________ Does this person require any special housing

accommodations? Yes No (circle one) If yes, please explain_________________________________________

____________________________________________________________________________________________

Privacy Act Notice: The information from this Questionnaire is to be used by District VI HRDC (agency for City of Lewistown) collecting it or its assignees in determining whether you qualify as a prospective borrower under the First Time Home Buyer Program. It will not be disclosed outside the agency except as required and permitted by law.

(OVER TO COMPLETE)

LIST SEPARATELY EACH HOUSHOLD MEMBERS GROSS MONTHLY INCOME

(enclose last two months pay stubs or print out from employer with this pre-application)

Name_________________________Employer__________________________________Gross Monthly Amount $________________

List all non-wage income below. Describe who gets the income and where it comes from. (Social Security, Railroad Retirement, etc)

____________________________________________________________________________________________________________________________________________________________________________________________________________

Other income and explanation (ie, loans from banks or family or friends, grants, etc.): _______________________________________

________________________________________________________________________________________________________________________________________
____________________________________________________________________

List below previous landlord references for last two years. (use additional paper if necessary)

This information is required

___________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

____________________________________________________________________

By signing this form I certify that all information is true & correct.

SIGNATURE:_____________________________________________________________DATE:_________________

CO-OWNER SIGNATURE:_________________________________________________DATE:__________________

NOTE: Returning this form does not guarantee eligibility.

Return this form to: First Time Home Buyer Project Manager, District 6 HRDC, 300 1^st Ave N. Suite 203, Lewistown, MT 59457, Phone (406)535-7488