Homeownership ProgramInformation & Pre-application Process

If you are ready to submit your pre-application for our Homeownership Program, you have the following options:

Submit your pre-application using the Drop Box located in the Information Room at our North Fort Myers office, during regular business, please check-in at the Front Desk

Insert your pre-application filled out completely and signed, along with all the forms and copies of required documentation in one of the envelopes located next to the Drop Box.

Submit your pre-application filled out completely and signed, along with all the forms and copies of required documentation, by mail to our North Fort Myers office, with attention to Family Services.

If you would like the Family Services staff to review your pre-application before submitting it, have additional questions, or you need to drop-off your pre-application outside business hours please set up an appointment by calling Daniela Rambhajan at 239-652-1672 or e-mail danielar@habitat4humanity.org

1288 N Tamiami Trail, North Fort Myers, FL 33903 | (239) 652-4663 | Habitat4Humanity.org

If you need information about our Homeownership Program, you have the following options:

Attend a virtual Homeownership Information Meeting Basic requirement to qualify for the Habitat Program Virtual meetings will last approximately 1 hour Virtual meetings are held regularly in English & Spanish Virtual meetings are held through Zoom You will find the schedule and links for registration in our website:

www.habitat4humanity.org

Walk-ins are accepted following CDC guidelines Check-in at the Front Desk for instructions

Call (239) 652-HOME (4663), Option 2

Please read carefully since starting July 1st, we are implementing new changes:

Please make sure to submit a complete pre-application along with all the forms and copies of all required documentation as per the pre-application Document Checklist (next page), your

pre-application cannot be processed until all required documentation is received.

Pre-applications are accepted during regular business days (Monday – Friday, from 9:00am to 5:00pm). If you need to drop off your pre-application outside business hours,

please set up an appointment.

Helpful Information:

• Pre-application must be filled out completely and signed by all members of the household who are age 18 and over.

• Authorization for the Release of Information must be filled out and signed (one for each household member who is 18 and over).

• Third-Party Verification Forms must include name and must be signed (one for each household member who is 18 and over, if applicable), do not fill out.

• If you or any household member who is 18 and over has a bank account at Wells Fargo and/or Bank of America, please print your name and sign the forms accordingly (do not fill out).

• The E-sign Consent Request Form must be filledout and signed (one for each applicant)

• Make sure you have the most updated Home Selection Form

• After your pre-application is submitted, additional documentation may be required

• Credit fee must be paid with a personal check or a money order, no cash or credit/debit cards accepted

• Submit original pre-application along with copiesof all required documentation

Pre-application and additional forms for all household members 18 and over• Pre-application• Authorization for the Release of Information• Third-Party Verification of Previous Employment Income

(if applicable)• Third-Party Verification of Household Employment Income

(if applicable)• Third-Party Verification of Household Asset Income, Wells

Fargo / Bank of America (if applicable) • E-Sign Consent Request Form

Copy of Valid Photo I.D. for all household members age 18 and over Copy of Driver License (color copy); or State-issued ID (color copy); and, If not a US Citizen, copy of Permanent Resident Card

(color copy of front and back)

Current Home Selection Form Mark all the homes that you would like to apply for

$36 Credit Report Fee Check or Money Order

Proof of Income for all household members age 18 and over (if applicable)If employed: Copies of most recent 4 consecutive paystubs for all current

employment Copies of two most recent tax returns (including W2 forms), only for

applicant and co-applicant

If self-employed: Copies of two most recent tax returns (including 1099 forms and

Schedule C). Current year-to-date Profit & Loss Statement

Benefits (Social Security, Disability, Retirement), if applicable: Copy of updated award letter stating the monthly benefit.

Alimony/Child Support (if applicable): Copy of court order showing amount awarded Copy of case history showing amounts disbursed If not court ordered, 6 months of payment history through bank

statements. If divorced, copy of divorce decree

Bank Statements for all household members age 18 and over (if applicable) Copies of most recent monthly statement for all bank accounts (must

show proof of enough funds for initial payment of $500 towards closing costs).

Your pre-application cannot be processed until all required documentation is received.

Complete Incomplete Return by: ___________

Homeownership ProgramInformation & Pre-application Process

1288 N Tamiami Trail, North Fort Myers, FL 33903 | (239) 652-4663 | Habitat4Humanity.org

You must have attended a Homeowner Information Meeting within the past 6 months.

You must have lived or worked in Lee or Hendry County for the past 12 months.

You must be a US Citizen or Permanent Resident. If married, you must apply with your spouse. You must have 2 years of verifiable income and the ability to repay the

mortgage. You must wait 3 years after foreclosure or bankruptcy has been

finalized. You must be able to show proof of funds for closing costs. Your household gross income must not exceed maximum amount

shown below for your family size:

LEE COUNTY HENDRY COUNTY

Family Size

Maximum Income

Family Size

Maximum Income

1 $38,600 1 $29,600

2 $44,100 2 $33,800

3 $49,600 3 $38,050

4 $55,100 4 $42,250

5 $59,550 5 $45,650

6 $63,950 6 $49,050

7 $68,350 7 $52,400

8 $72,750 8 $55,800

Homeownership ProgramInformation & Pre-application Process

1288 N Tamiami Trail, North Fort Myers, FL 33903 | (239) 652-4663 | Habitat4Humanity.org

Pre-Application Habitat Homeownership Program

v9.0

We are pledged to the letter and spirit of U.S. policy for the achievement of equal housing opportunity throughout the nation. We encourage and support an affirmative advertising and marketing program in which there are no barriers to obtaining housing because of race, color, religion, sex, handicap, familial status, or national origin.

1. A P P L I C A N T I N F O R M AT I O N

Applicant Co-applicant

Applicant’s name Co-applicant’s name

Social Security number Telephone #

________________________ ______________________________

Date of Birth Yrs. School

______________________ ______________________________

□ Married □ Separated □ Unmarried (Incl. single, divorced, widowed

Social Security number Telephone #

___________________________ __________________________________

Date of Birth Yrs. School

________________________ _______________________________

□ Married □ Separated □ Unmarried (Incl. single, divorced, widowed)

E-mail: E-mail:

Dependents and others who will live with you (not listed by co-applicant) Dependents and others who will live with you (not listed by co-applicant)

Name DOB Male Female Name DOB Male Female

□ □ □ □

□ □ □ □

□ □ □ □

□ □ □ □

Present address (street, city, state, ZIP code) □ Own □ Rent

Number of years

Present address (street, city, state, ZIP code) □ Own □ Rent

Number of years

If l iving at present address for less than two years, complete the fol lowing

Last address (street, city, state, ZIP code) □ Own □ Rent

Number of years

Last address (street, city, state, ZIP code) □ Own □ Rent

Number of years

Date received:

Date of notice of incomplete application letter:

Date of adverse action letter:

Date of letter to proceed:

Date of information meeting attendance: ________________________________

Home Selection(s): __________________________________________________

Date of Selection Committee Approval: __________________________________ _________

Date of Partnership Agreement: ___________________________________________________

Dear Applicant: Please complete this pre-application to determine if you qualify for the Habitat for Humanity homeownership program. Please fill it out as completely

and accurately as possible. All information you include on this pre- application will be kept confidential in accordance with the Gramm-Leach-Bliley Act.

2. FOR O F F I C E USE ONLY – DO NOT W R I T E IN THIS SPACE

To be considered for Habitat homeownership, you and your family must be willing to complete a certain number of “sweat-equity” hours. Your help in

building your home and the homes of others is called “sweat equity” and may include clearing the lot, painting, helping with construction, working in

the Habitat office or other approved activities.

I AM WILLING TO COMPLETE THE REQUIRED SWEAT-EQUITY HOURS:

Yes No

Applicant □ □ Co-applicant □ □

Number of bedrooms (please circle) 1 2 3 4 5

Other rooms in the place where you are currently living:

□ Kitchen □ Bathroom □ Living room □ Dining room □ Other (please describe)

Yes No

Was your home impacted by Hurricane Irma? □ □

Were you displaced by Hurricane Irma? □ □

If you rent your residence, what is your monthly rent payment? $ / month

(Please supply a copy of your lease or a copy of a money order receipt or canceled rent check.)

Name, address and phone number of current landlord:

If you own your residence, what is your monthly mortgage payment? $ / month Unpaid balance $

Do you own land? □ No □ Yes Monthly payment $

Unpaid balance $

6. E M P L O Y M E N T I N F O R M AT I O N

Applicant Co-applicant

Name and address of CURRENT employer From To Name and address of CURRENT employer From To

Pay Rate: $

Hours per week: #

Pay Rate: $

Hours per week: #

Job Title Paid: Weekly _____

Bi-Weekly _____

Other ______________

_____

Business phone Job Title Paid: Weekly _____

Bi-Weekly _____

Other ______________

Business phone

If working at current job less than two years, complete the following information

Name and address of LAST employer From To Name and address of LAST employer From To

Pay Rate: $

Hours per week: #

Pay Rate: $

Hours per week: #

Job Title Paid: Weekly _____

Bi-Weekly _____

Other ______________

Business phone Job Title Paid: Weekly _____

Bi-Weekly _____

Other ______________

Business phone

3. W I L L I N G N E S S TO P A R T N E R

4. P R E S E N T H O U S I N G C O N D I T I O N S

5. P R O P E R T Y I N F O R M AT I O N

In the space below, describe the condition of the house or apartment where you live.

Why do you need a Habitat home?:

7. HOUSING NEEDS

Please enter all monthly income. Alimony, child support or separate maintenance income need not be revealed if the applicant or co-applicant does not chose to have it considered for repaying this loan.

Income Source Applicant Co-applicant Others in household Total

Employment Income $ $ $ $

TANF $ $ $ $

Alimony $ $ $ $

Child support $ $ $ $

Social Security $ $ $ $

SSI $ $ $ $

Disability $ $ $ $

Other ______________ $ $ $ $

Other $ $ $ $

Other $ $ $ $

Other $ $ $ $

Total $ $ $ $

PLEASE NOTE: Self-employed applicants

may be required to provide

additional documentation

such as tax returns and

financial statements.

Household members whose income is n o t listed above

Name Income source Monthly income Date of birth

Do you have sufficient funds saved to make payments toward your closing costs? If not, where will you get the money to pay for closing costs?

10. A S S E T S

Name of bank, savings and

loan, credit union, etc.

Address

City, state

ZIP

Account number Current

balance

$

$

$

$

$

$

$

$

$

8. MON THL Y I N C O M E

9. S O U R C E OF C L O S I N G COS TS

To whom do you and the co-applicant(s) owe money?

Applicant Co-applicant

Account Monthly

payment

Unpaid

balance

Months

left to pay

Monthly

payment

Unpaid

balance

Months

left to pay

Automobile $ $ $ $ $ $

Other motor vehicle/boat $ $ $ $ $ $

Furniture, appliance, televisions

(includes rent-to-own)

$

$

$

$

$

$

Alimony $ $ $ $ $ $

Child support $ $ $ $ $ $

Student Loan $ $ $ $ $ $

Payday\Title loans $ $ $ $ $ $

Credit card $ $ $ $ $ $

Total medical $ $ $ $ $ $

Other $ $ $ $ $ $

Other $ $ $ $ $ $

Total $ $ $ $ $ $

Monthly expenses

Account Applicant Co-applicant Total

Rent $ $ $

Utilities $ $ $

Insurance $ $ $

Child care $ $ $

Internet service $ $ $

Cell phone $ $ $

Landline $ $ $

Groceries $ $ $

Other $ $ $

Other $ $ $

Other $ $ $

Other $ $ $

Total $ $ $

1 1 . D E B T

12. D E C L A R AT I O N S

Please circle the word that best answers the following questions for you and the co-applicant

Applicant Co-applicant

a. Do you have any outstanding judgments because of a court decision against you? □ Yes □ No □ Yes □ No

b. Have you been declared bankrupt within the past three years? □ Yes □ No □ Yes □ No

c. Have you had property foreclosed on in the past three years? □ Yes □ No □ Yes □ No

d. Are you currently involved in a lawsuit? □ Yes □ No □ Yes □ No

e. Are you paying alimony or child support? □ Yes □ No □ Yes □ No

f. Are you a U.S. citizen or permanent resident? If Permanent Resident, in what country

were you born? ________________________________________.

□ Yes □ No □ Yes □ No

g. Have you ever served in the military? □ Yes □ No □ Yes □ No

h. Have you ever applied for a Habitat home before? □ Yes □ No □ Yes □ No

If you answered “no” to question f, or "yes" to any other question, please explain.

I understand that by filing this pre-application, I am authorizing Habitat for Humanity to evaluate my actual need for the Habitat homeownership

program, my ability to repay the loan and other expenses of homeownership, and my willingness to be a partner through sweat equity.

I understand that Habitat for Humanity may require me to work with their HUD approved Housing Advisors. I authorize Habitat for Humanity to

share my information with their Housing Advisors.

I understand that the evaluation will include personal visits, a credit check and employment verification. I have answered all the questions on this

application truthfully. I understand that if I have not answered the questions truthfully, my application may be denied, and that even if I have already

been selected to receive a Habitat home, I may be disqualified from the program. The original application will be retained by Habitat for Humanity

along with all related documentation even if the application is not approved. I understand that additional requirements must be met before being

selected for the Habitat program.

I also understand that Habitat for Humanity screens all applicant families on the sex offender registry. By completing this application, I am submitting

myself to such an inquiry. I further understand that by completing this application, I am submitting myself to a criminal background check.

Applicant signature Date Co-applicant signature Date

X X

Print name __________________________________________ Print name______________________________________________

Other household members 18 years and older:

I understand that Habitat for Humanity screens all partner families on the sex offender registry. By signing below, I am submitting myself to such an

inquiry. I further understand that by signing this application, I am submitting myself to a criminal background check.

Print Name: _________________________________ Date: ___________________ Print Name: _________________________________ Date: ___________________

Signature: Signature:

PLEASE NOTE: If more space is needed to complete any part of this application, please use a separate sheet of paper and attach it to this application.

Please mark your additional comments with “A” for applicant or “C” for co-applicant.

This is to notify you that we may order an appraisal in connection with your loan and we may charge you for this appraisal. Upon completion for

the appraisal, we will promptly provide a copy to you, even if the loan does not close.

Applicant’s signature ____________________________________________ Co-applicant’s signature ____________________________________________

13. A U T H O R I Z AT I O N AND R E L E A S E

14. R I G H T T O R E C E I V E C O P Y O F A P P R A I S A L

PLEASE READ THIS STATEMENT BEFORE COMPLETING THE BOX BELOW: The following information is requested by the federal government for

loans related to the purchase of homes, in order to monitor the lender’s compliance with equal credit opportunity and fair housing laws. You are not

required to furnish this information, but are encouraged to do so. The law provides that a lender may neither discriminate on the basis of this

information, nor on whether you choose to furnish it or not. However, if you choose not to furnish it, under federal regulations this lender is

required to note ethnicity, race and sex on the basis of visual observation or surname. If you do not wish to furnish the information below, please

check the box below.

Applicant Co-applicant

□ I do not wish to furnish this information

Race (applicant may select more than one racial designation):

□ American Indian or Alaska Native

□ Native Hawaiian or other Pacific Islander

□ Black/African-American

□ White

□ Asian

Ethnicity:

□ Hispanic or Latino □ Non-Hispanic or Latino

Sex:

□ Female □ Male

Birthdate: / /

Marital status:

□ Married

□ Separated

□ Unmarried (Incl. single, divorced, widowed)

□ I do not wish to furnish this information

Race (applicant may select more than one racial designation):

□ American Indian or Alaska Native

□ Native Hawaiian or other Pacific Islander

□ Black/African-American

□ White

□ Asian

Ethnicity:

□ Hispanic or Latino □ Non-Hispanic or Latino

Sex:

□ Female □ Male

Birthdate: / /

Marital status:

□ Married

□ Separated

□ Unmarried (Incl. single, divorced, widowed)

To be completed only by the person conducting the interview

This application was taken by:

□ Face-to-face interview

□ By mail

□ By telephone

Interviewer’s name (print or type)

Interviewer’s signature Date

Interviewer’s phone number

Revised on 10-9-19

15. I N F O R M AT I O N FOR G O V E R N M E N T M O N I T O R I N G P U R P O S E S

Habitat for Humanity of Lee and Hendry Counties, Inc. Privacy Statement and Notice

At Habitat for Humanity of Lee and Hendry Counties, Inc., we are committed to keeping your information private. We recognize the importance applicants, partner families, tenants, and homeowners place on the privacy and confidentiality of their information. While new technologies allow us to more efficiently serve our customers, we are committed to maintaining privacy standards that are synonymous with our established and trusted name. When collecting, storing, and retrieving applicant, partner family, tenant, and homeowner data –such as tax returns, pay stubs, credit reports, employment verifications and payment history– internal controls are maintained throughout the process to ensure security and confidentiality. We collect nonpublic personal information about you from the flowing sources:

• Information we receive from you on applications or other forms;

• Information about your transactions with us, our affiliates, or others;

• Information we receive from a consumer reporting agency;

• Information we receive from you during interviews We may disclose the following kinds of nonpublic personal information about you:

• Information we receive from you on applications or other forms, such as name, address, social security number, income, age, assets, family size, ethnicity, and other information from the application;

• Information about your transactions with us, our affiliates, or others such as your payment history or amounts due to us;

• Information we receive from a consumer reporting agency such as your credit history;

• Information gathered from interviews with us, such as family size

Habitat for Humanity of Lee and Hendry Counties, Inc., employees and volunteers are subject to a written policy regarding confidentiality and access to applicant data is restricted to staff and volunteers on an as-needed basis. Information is used for lawful business purposes and is never shared with third parties without your consent, except as permitted by law. As permitted by law, we may disclose nonpublic personal information about you to the following types of third parties:

• Financial service providers, such as mortgage servicing agents or banks providing loan funding;

• Nonprofit organizations, public sector agencies or governments

We may also disclose nonpublic information about you to nonaffiliated third parties as permitted by law, in connection with our normal operating practices. We do not disclose any nonpublic personal information about you to anyone, except as permitted by law. We maintain physical, electronic and procedural safeguards that comply with federal regulations to guard your nonpublic personal information. I acknowledge that I have received a copy of Habitat for Humanity of Lee and Hendry Counties, Inc. Privacy Statement and Notice. Applicant Signature Date Co-applicant Signature Date ____________________________________ _______________________________________ Print Name __________________________ Print Name ______________________________

Habitat for Humanity of Lee and Hendry Counties, Inc. Equal Credit Opportunity Act Notice

The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant’s income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The Federal Agency that monitors compliance with this law concerning this company is the Federal Trade Commission for the Southeast Region with offices at: Suite 1500, 225 Peachtree Street NE, Atlanta GA 30303 or Federal Trade Commission, Equal Credit Opportunity, Washington, DC 20580.

You need not disclose income from alimony, child support or separate maintenance payment if you choose not to do so. However, because we operate a Special Purpose Credit Program, we may request and require it, in order to determine an applicant’s eligibility for the program and the affordable mortgage amount, information regarding the applicant’s marital status; alimony, child support and separate maintenance income; and the spouse’s financial resources.

Accordingly, if you receive income from these resources and do not provide this information with your application, your application will be considered incomplete and we will be unable to invite you to participate in the Habitat program.

I acknowledge that I have received a copy of Habitat for Humanity of Lee and Hendry Counties, Inc. Equal Credit Opportunity Act Notice.

Applicant Signature Date Co-applicant Signature Date

____________________________________ _____________________________________

Print Name __________________________ Print Name ____________________________

We are pledged to the letter and spirit of U.S. policy for the achievement of equal housing opportunity throughout the nation. We encourage and support an affirmative advertising and marketing program in which there are no barriers to obtaining housing because of race, color, religion, sex, handicap, familial status, or national origin.

HOUSEHOLD AUTHORIZATION FOR THE RELEASE OF INFORMATION Please copy forms as necessary – one for each applicable household member (including minors)

I ________________________________________, the undersigned, hereby authorize the release without

liability, information regarding my employment, income, and/or assets to Habitat for Humanity, for the

purposes of verifying information provided as part of determining eligibility for assistance. I understand that

only information necessary for determining eligibility can be requested.

Types of Information to be verified:

I understand that previous or current information regarding me may be required. Verifications that may be

requested are, but not limited to:

1. Personal identity 2. Employment history

3. Hours worked 4. Salary and payment frequency,

5. Commissions, anticipated raises 6. Bonuses

7. Tips 8. Cash held in checking accounts

9. Cash held in savings accounts 10. Interest earned from checking/savings accounts

11. Dividends earned from checking/savings accounts 12. Stocks

13. Bonds 14. Certificates of Deposit (CD)

15. Individual Retirement Accounts (IRA) 16. Payments from Social Security

17. Annuities 18. Insurance policies

19. Retirement funds 20. Pensions

21. Disability or death benefits 22. Unemployment

23. Disability or worker’s compensation 24. Welfare assistance

25. Net income from the operation of a business 26. Alimony or child support payments.

Organizations/Individuals that may be asked to provide written/oral verifications are, but not limited to:

1. Past/Present Employers 2. Alimony/Child Support Providers

3. Banks, Financial or Retirement Institutions 4. Social Security Administration

5. State Unemployment Agency 6. Veteran’s Administration

7. Welfare Agency 8. Other: ______________________________

Agreement to Conditions:

I agree that a photocopy of this authorization may be used for the purposes stated above. I understand that I

have the right to review this file and correct any information found to be incorrect.

Signature of Applicant Printed Name Date

Note: This general consent may not be used to request a copy of a tax return. If one is needed, contact your

local IRS office for Form 4506, “Request for Copy of Tax Return” and prepare and sign separately.

THIRD-PARTY VERIFICATION OF HOUSEHOLD EMPLOYMENT INCOME Please copy forms as necessary – one for each applicable household member (including minors)

State and/or Federal Regulations require us to verify employment history and income information for the person

that has provided authorization below, in order to determine their eligibility for program assistance. Your

cooperation in providing the requested information below is most appreciated.

Authorization:

I hereby authorize the release of requested information. A copy of the executed “Authorization for the Release

of Information” is attached which indicates my agreement with the release of information requested for the sole

purpose of determining eligibility for program assistance.

Signature of Applicant Print Name Date

Co-Applicant/Household Member Print Name Date

Please complete the applicable sections below:

Employer/Company Name:

Address:

City: State: Zip Code:

Employee Name: ______________________________________________

**************************Applicants – Do Not Write Below This Line**************************

Please provide information about anticipated employment income during the next 12 months:

Position: ______________________ Length of Time Employed: ________Date of Hire (mm/dd/yy):________

Pay Rate: $________________Pay Frequency (Hr, Wk, Mo): ____________ # of Hours Per Week:

Overtime Pay Rate: $________ Average Overtime Hours/Wk: _____ Likely to Continue? (circle one): Yes No

Total Annual Base Pay Earnings: $_______________Total Overtime Base Pay Earnings: $_________________

Amount and Frequency of Other Compensation (bonus, raise, commission, tips): $ _______________________

Vacation Pay (Y or N): _____________________________ If yes, number of days: ______________________

Retirement Account (Y or N): _______________ Amount Accessible to Employee: $ ____________________

Total Gross Annual Income, including other compensation, for next 12 months: $ ________________________

Signature of Authorized Representative: _________________________________________________________

Printed Name: Title:

Date:_________________________________________________ Phone: ______________________________

WARNING: Florida Statute 817 provides that willful false statements or misrepresentation concerning income, asset or

liability information relating to financial condition is a misdemeanor of the first degree, punishable by fines and

imprisonment provided under Statutes 775.082 and 775.083.

Please return information to: Housing Finance – Daniela Medina Habitat for Humanity of Lee and Hendry Counties, Inc. 1288 N. Tamiami Trail N. Fort Myers, FL 33903 Fax: 239-652-3335

THIRD-PARTY VERIFICATION OF PREVIOUS EMPLOYMENT INCOME Please copy forms as necessary – one for each applicable household member (including minors)

State and/or Federal Regulations require us to verify employment history and income information for the person

that has provided authorization below, in order to determine their eligibility for program assistance. Your

cooperation in providing the requested information below is most appreciated.

Authorization:

I hereby authorize the release of requested information. A copy of the executed “Authorization for the Release

of Information” is attached which indicates my agreement with the release of information requested for the sole

purpose of determining eligibility for program assistance.

Signature of Applicant Print Name Date

Co-Applicant/Household Member Print Name Date

Please complete the applicable sections below:

Employer/Company Name:

Address:

City: State: Zip Code:

Employee Name: ______________________________________________

**************************Applicants – Do Not Write Below This Line**************************

Please provide information about anticipated employment income during the next 12 months:

Position: _________________________________ Date of Hire (mm/dd/yy): ___________ to _____________

Pay Rate: $________________Pay Frequency (Hr, Wk, Mo): ____________ # of Hours Per Week:

Overtime Pay Rate: $________ Average Overtime Hours/Wk: _____

Total Annual Base Pay Earnings: $_______________Total Overtime Base Pay Earnings: $_________________

Amount and Frequency of Other Compensation (bonus, raise, commission, tips): $ _______________________

Retirement Account (Y or N): _______________ Amount Accessible to Employee: $ ____________________

Total Gross Annual Income, including other compensation, for next 12 months: $ ________________________

YTD as of (mm/dd/yy) _______________ (if applicable)

Signature of Authorized Representative: _________________________________________________________

Printed Name: Title:

Date:_________________________________________________ Phone: ______________________________

WARNING: Florida Statute 817 provides that willful false statements or misrepresentation concerning income, asset or

liability information relating to financial condition is a misdemeanor of the first degree, punishable by fines and

imprisonment provided under Statutes 775.082 and 775.083.

Please return information to: Housing Finance – Daniela Medina Habitat for Humanity of Lee and Hendry Counties, Inc. 1288 N. Tamiami Trail N. Fort Myers, FL 33903 Fax: 239-652-3335

THIRD-PARTY VERIFICATION OF HOUSEHOLD ASSET INCOME Please copy forms as necessary – one for each applicable household member (including minors)

State and/or Federal Regulations require us to verify asset income information for the person that has provided

authorization below, in order to determine their eligibility for program assistance. Your cooperation in providing the

requested information below is most appreciated.

Authorization:

Signature of Applicant Print Name Date

Co-Applicant/Household Member Print Name Date

To: Institution Name:________________________________________________________________________

Address: ________________________________ City: ____________________ State: ______ Zip: _________

**************************Applicants – Do Not Write Below This Line************************** Please Complete the (applicable) Sections below:

Checking Account No. Average Monthly Balance

Last 6 Months

Current Interest Rate

Savings Account No. Current Balance Current Interest Rate

Money Market Account No. Average Monthly Balance

Last 6 Months Current Interest Rate

Certificate of Deposit Account No. Amount Current Interest Rate Withdrawal penalty

IRA, Keogh, Retirement Account

No. Amount Current Interest Rate Withdrawal penalty

Other Account No. Amount Current Interest Rate Withdrawal penalty

Signature of authorized representative: ________________________________________________________

Printed Name: _____________________ Title: _________________ Date: _________ Phone: _____________

WARNING: Florida Statute 817 provides that willful false statements or misrepresentation concerning income, asset or

liability information relating to financial condition is a misdemeanor of the first degree, punishable by fines and

imprisonment provided under Statutes 775.082 and 775.083.

Please return information to: Family Services - Karen Rodriguez Habitat for Humanity of Lee and Hendry Counties, Inc. 1288 N. Tamiami Trail N. Fort Myers, FL 33903 Fax: 239-652-3335

SECTION 1: REQUESTER INFORMATION

SECTION 2: CUSTOMER INFORMATION

This form is for medical or public assistance agencies requesting consumer deposit information. Please complete the form including thecustomer authorization signature and fax to the number below. Your completed request will be faxed to the return fax number providedon this form.

Month Day Year/ / 2 0

Account Number(s) (Required)

Customer One Social Security Number- -

Customer One Full Name (First Middle Last)

Customer Two Full Name (First Middle Last)

Verification of DepositMedical or Public Assistance Agencies

Company Name

Attention

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Requester Phone Number- -

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TYPE or complete in BLACK INK. Use only CAPITAL LETTERS

For faster processing, please complete the form on your computer before printing.

Fax Requests To.............................................................................................................................................................1-844-879-0412Online Instructions...............................................................................................................................www.wellsfargo.com/biz/vodBalance Confirmation Services...................................................................................................................................1-540-563-7323

CUSTOMER AUTHORIZATION

Signature of Account Holder DateSignature of Account Holder Date

I/We authorize and direct Wells Fargo Bank to release the following information to the above mentioned requestor on my depositaccounts listed above or if only a Social Security Number is provided, all open depository accounts: Account Number, Account Type,Open or Closed, Account Holder(s), Current/Closing Balance, Open/Close Date, Current Interest Rate, Previous Six Average StatementBalances and Previous Six Months Interest Paid. In addition, CDs and IRAs will include: Term, Maturity Date, Interest Payment, InterestMethod and Penalty.

18618

Habitat for Humanity of Lee and Hendry Counties, Inc - Karen Rodriguez 239 349-7224 239 652-3335

E-SIGN CONSENT Request Form Please copy form – one for each applicant

I agree that information related to my application for a Habitat home including but not limited to, correspondence, notices, subject property evaluations, initial loan disclosures and/or re-disclosures pertaining to the home loan transaction and housing counseling sessions will be provided or made available either on paper or electronically, at the discretion of Habitat for Humanity of Lee and Hendry Counties, Inc.

By initialing this box, I hereby request that you send me an E-Sign Consent Form via email. My e-mail address is_______________________________________________________ . I will sign and return the electronic E-Sign Consent Form via electronic submission consenting to electronic communications. I understand that the hardware and software I must have to receive this document is a computer with internet access and a minimum Internet Explorer and Adobe Reader.

I hereby represent to you that I have the required hardware and software as above

described. You may withdraw your consent to receive information in electronic form at any time by giving us five (5) working days advanced notice in writing. That notice may be sent by first-class mail to us at 1288 N. Tamiami Trail, N. Fort Myers, or to your Housing Finance Coordinator. During the loan process, if you change your e-mail address, you must notify us of your new address within five (5) working days by mail or secure email in order to receive notification. If Habitat for Humanity of Lee and Hendry Counties, Inc. receives a notice that your email address is unreachable or undeliverable, your account will be switched to receive paper notifications only and we will no longer be able to communicate electronically.

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