Pre-Screening Application
Head of Household Name
Co-Applicant Name
Mailing Address
County
City, State, Zip
Address (if different from above)
Phone
Email
# of Adults in family
# Children in family
Marital status
Married
Unmarried
Gross annual family income ($ Amount)
Gross monthly family income ($ Amount)
Gross weekly family income ($ Amount)
Employer's name
What ties do you have in the city you are applying to live in
Family
Friends
Employment
How did you hear of our program
Do you own property
Yes
No
Address of property, if applicable
Do you have family who own a Habitat home
Yes
No
If family owns Habitat home, what is address
Verification No.
