LNDF &  LCLF INTAKE FORM - Print Version

Print this page or contact our office to get a blank copy of the application.
Fill out as much information as possible

Completed form gets mailed to:
Lynchburg Neighborhood Development Foundation
927 Church Street, Lynchburg, VA  24504


1. General Information
Date: _____________________________  

NAME:

____________________________________________

Social Security #

_______________

Date of Birth

______________

Co-OWNER/SPOUSE NAME:

_____________________________________________

Social Security #

_________________

Date of Birth

______________

 

ADDRESS:        ________________________________________________________

CITY/STATE:    _______________________________________

ZIP:                    ___________

PHONE # (H)    __________________________

(W)   __________________________

Co-applicant (W) __________________________

MOST CONVENIENT TIME TO SET UP AN APPOINTMENT  _____________________________________

MARITAL STATUS (select one) :   Single      Married      Divorced     Widowed

DEPENDENTS:
Names:
__________________________________

__________________________________

__________________________________


Ages:
________

________

________ 


2. Residential  Information

LANDLORD'S NAME: _______________________________________

LANDLORD'S PHONE NUMBER ________________________

LANDLORD'S ADDRESS: _______________________________________

LANDLORD'S CITY/STATE ________________________

TIME LIVED AT THE ABOVE ADDRESS __________        MO. RENT $___________        MO. UTILITIES: ____________________________

IF LESS THAN TWO YEARS, PREVIOUS ADDRESS:

___________________________________________________________________________________


3. Employment and Income

HOUR: $___________

WEEK: $___________

MONTH: $______________

YEAR: $______________

  GROSS MONTHLY INCOME:     $____________________       


EMPLOYER: _________________________________________________

ADDRESS___________________________________________________

PART TIME / Full Time (select one)  

LENGTH OF TIME AT CURRENT EMPLOYMENT _____________________________  


IF LESS THAN TWO YEARS, PREVIOUS EMPLOYMENT
________________________________________________

Other Income Sources

CHILD SUPPORT MONTHLY     $____________________       

PENSION/DISABILITY/SOCIAL SECURITY     $____________________       

(APPLICANT) SOURCE :  ____________________________________  $____________________       

(CO-OWNER/SPOUSE) SOURCE____________________________________   $____________________       

  INTEREST ON SAVING    

 

BANK Name: ____________________________________     $____________________       

OTHER: SOURCE:    ___________________________________________________     $____________________       

TOTAL INCOME FROM ALL SOURCES:     $____________________       


4. Housing Priorities

Location:
1st choice:__________________________________________            
                 (city/town)

__________________________________________
(county)

Location:
2nd choice:__________________________________________
                 (city/town
)


___________________________________________
(county
)

number of bedrooms:________________________

special needs (handicapped, elderly): _____________________________

have you owned a home in the past three years?    (circle one)   yes / no

are you currently residing in public housing?   (circle one)   yes / no

are you currently participating in any self-sufficiency program such as project self-sufficiency, etc? (circle one)   yes / no

If yes, describe the program:

___________________________________________________________________________________________


5. Information for Goverment Monitoring Purposes

The following information is requested by the federal government for certain types of loan applications related to a dwelling, in order to monitor compliance with equal opportunity, fair housing and home mortgage disclosure laws.  You are not required to furnish this information, but are encouraged to do so.

BORROWER:

CO-BORROWER

____   I DO NOT WISH TO FURNISH THIS INFORMATION

_____  I DO NOT WISH TO FURNISH THIS INFORMATION

RACE/NATIONAL ORIGIN

RACE/NATIONAL ORIGIN

Print Applicant
Please circle as many as apply
AMERICAN INDIAN
BLACK, NON-HISPANIC
WHITE, NON-HISPANIC
HISPANIC
OTHER _______________________

Print Applicant
Please circle as many as apply
AMERICAN INDIAN
BLACK, NON-HISPANIC
WHITE, NON-HISPANIC
HISPANIC
OTHER _______________________

SEX (select one) M / F

SEX: (select one) M / F


6. Certification

I certify that all of the above information is correct and true to the best of my knowledge.  I understand that false or misleading information may be grounds for rejection of my application.  Furthermore, I understand that the completion of the application in no way guarantees me that I will receive housing.  I hereby authorize the agency to obtain a Credit Bureau Report in my name, and/or to request verification of income and residence.

___________________________________________________
APPLICANT'S SIGNATURE

_______________________
DATE

___________________________________________________
CO-APPLICANT'S SIGNATURE

_______________________
DATE


7.  Referral Source

HOW DID YOU HEAR ABOUT OUR SERVICES?

Print Applicant
Please circle one
MAIL OUT
WORD OF MOUTH
FLYER
BROCHURE
NEWSPAPER
T.V.
RADIO
BANKER
Other: ______________