Mutual Self-Help Housing Program Application

SUBMIT APPLICATION WITH RECENT FOUR (4) PAYSTUBS FOR EACH APPLICANT, OR EQIVALENT

Applicant Name:
Mailing Address: Street , Apt., City, State, Zip
Physical Address:
 Same as above
Phone: Email:
INCOME
Employment Began Hours worked
Employer(s) (If applicable) (MM/YY) Position Held Rate of Pay / Hour per week

Previous Employer Employment Dates Hours worked

(If current is less than 2 years) (MM/YY - MM/YY) Position(s) Held Rate of Pay per week

ADDITIONAL SOURCES OF INCOME (if applicable) (i.e. Retirement, Social Security, Spousal Support, Disability, Child Support, etc.)
Amount Received Amount Received
Source of Income (monthly) Source of Income (monthly)
$ $

$ $
Do you have student loans?  Yes  No If yes, are they in repayment?  Yes  No

Do you have assets exceeding $15,000 in value (i.e. cash, stocks, bonds)?  Yes  No If yes, what?

Co-Applicant Name: (if applicable)

Physical Address: Street, Apt., City, State, Zip
 Same as above
Phone: Email:
Employment Began Hours worked
Employer(s) (If applicable) (MM/YY) Position Held Rate of Pay per week

Other Source(s) of Income: (if applicable) Monthly received: $

Other Source(s) of Income: (if applicable) Monthly received: $

Do you have student loans?  Yes  No If yes, are they in repayment?  Yes  No
Do you have assets exceeding $15,000 in value (i.e. cash, stocks, bonds)?  Yes  No If yes, what?

Please continue to next page...

Page 1 / 4
 ADDITIONAL HOUSEHOLD MEMBERS
Additional Adult Name: Gross Annual Income:

Number of minors (under 18 years of age): Age(s):

Monthly Childcare Expense(s) $

Are you paying for child support?  Yes  No If yes, what is your monthly payment? $____________
Do you have a parenting plan?  Yes  No
If you are receiving child support, are the payments current?  Yes  No If yes, for how long? ____________

RENTAL HISTORY
If currently renting from a landlord, are you on the lease?  Yes  No
If you have lived here less than 2 years, do you have a 2+ year rental history altogether?  Yes  No
Current Rent Payment (monthly) Move-in Date (MM/YY) Renting from family? Do you have a Section 8
$  Yes  No Voucher?  Yes  No

ACCOUNT INFORMATION
Do you have any of the following (Please Check Mark to Indicate “Yes”):
 Bankruptcy (If yes, Discharge Date __________)  Unpaid Collections  Unpaid Charge-Offs
 Foreclosure within Recent 36 Months from Date of Application
 Missed or 30+ Day Late Payments within Recent 12 Months from Date of Application
 Unsatisfied Judgements (If yes, Satisfied Date __________)  Other ______________________

LOCATION PREFERENCE
OPTIONAL

Anywhere Mason County ____ Anywhere Kitsap County ____

Port Orchard ____ Silverdale ____ Poulsbo____ Kingston ____

The following information is requested by the Federal Government in order to monitor our compliance with Federal Laws to help ensure that we do not
discriminate against you based on your ethnicity, race, or gender. You are not required to provide this information, but if you choose not to, we are required by law
to make our best guess, based on our visual observation or your surname.

APPLICANT  Do not wish to provide CO-APPLICANT  Do not wish to provide

Race (check all that apply) Race (check all that apply)
 American Indian or Alaska Native  Asian  American Indian or Alaska Native  Asian
OPTIONAL

 Native Hawaiian or other Pacific Islander  Native Hawaiian or other Pacific Islander
 Black or African American  White  Other________  Black or African American  White  Other________
Ethnicity:  Hispanic or Latino  Not Hispanic or Latino Ethnicity:  Hispanic or Latino  Not Hispanic or Latino
Gender:  Male  Female Gender:  Male  Female
Military Affiliation:  Active Military  Veteran Military Affiliation:  Active Military  Veteran
OPTIONAL

HOW DID YOU HEAR ABOUT US?  Friend  Self-Help Homeowner  Website  Other Agency  Flyer/Brochure
 Employer  Community Event  Vehicle Sign  Self-Help Property Sign  Newspaper  Other______________________

Please continue to next page...

Page 2 / 4
ACCOUNT INFORMATION (Continued)
Debts and Liabilities
(i.e. Credit Cards, Loans and Other Remaining Minimum Monthly
Additional Information / Comments
Monthly Payments such as Utilities, Balance Payment Required
Phone, Insurance, Etc.)

COMMITMENT
Are you willing to contribute up to 35 labor hours per week until your home is complete? YES / NO
Volunteers may be used to help. If no, please explain:

Is there anything that may prohibit your household from contributing the required labor hours? YES / NO
If yes, please explain:

Will the home you build with Housing Kitsap be the primary residence for everyone on this application? YES / NO
If no, who will not be included in the household as their primary residence?

I certify that the above information is true and correct to the best of my knowledge. By signing this application, I acknowledge
that I must participate in building my home in accordance to the required sweat equity labor hours and abide by a Group
Labor Agreement. I further acknowledge I am encouraged to ask questions to Housing Kitsap staff members to better
understand the program, my home loan and the construction process.

_____________________________________ ____________ __________________________________ ______________

Applicant Signature Date Co-Applicant Signature Date

SOCIAL SECURITY NUMBER ________________________ SOCIAL SECURITY NUMBER ______________________

DATE OF BIRTH _____________________ DATE OF BIRTH____________________

CREDIT PULL AUTHORIZATION

Please note: Without this acknowledgement, this application is considered incomplete and will not be processed.
I hereby authorize Housing Kitsap to verify my past and present employment earnings records, bank accounts, retirement
accounts and other asset balances needed to process my/our mortgage application. I/We further authorize Housing Kitsap to
order a credit report and verify other credit information at any time during the application process, including past and present
landlord references. I/We understand that a photocopy of this form will also serve as authorization. The information obtained by
Housing Kitsap is only to be used in the processing of my/our application for a mortgage loan. All applications will be maintained
using a digital database under Housing Kitsap’s care.

____________________________________ ____________ _________________________________ ______________

Applicant Signature Date Co-Applicant Signature Date

Page 3 / 4
Minimum qualifications for loan eligibility may include: Two (2) years of verifiable employment in the same line of
work, decent credit and gross (before taxes) annual household income of approximately $32,000 or more.
We encourage you to submit an application for a free eligibility evaluation at any time.

TIME TO SUBMIT!

SUBMIT YOUR APPLICATION AND RECENT FOUR (4) PAYSTUBS, OR EQUIVALENT

IN ONE OF THE FOLLOWING WAYS:

MAIL/DROP-OFF:
Housing Kitsap FAX: ATTN: Self-Help Intake, (360) 535-6169
ATTN: Self-Help Intake
EMAIL: SelfHelpWaitlist@housingkitsap.org
2244 NW Bucklin Hill Road
Silverdale, WA 98383

For questions, call Housing Kitsap:

Local: (360) 535-6139  TDD/TTY: (360) 535-6106  Toll Free: 1(800) 693-7070 x 6139

This program made possible by:

This is an Equal Opportunity Program. Discrimination is prohibited by Federal Law. Complaints of discrimination may be
filed with USDA, Office of Civil Rights, 1400 Independence Ave., SW Washington, DC 20250-9410 Telephone: (866) 632-9992 TDD (202) 401-0216

Page 4 / 4