Interest Form

Please review the Apply for a Home web page before submitting this form . Please note that this Interest Form is NOT an application for a Habitat home, but provides us with your contact information so that we can send you more information. Please allow up to 4 weeks for information to be provided to you.

YOUR INFORMATION *First Name:
*Last Name:
*Address:
*City:
*State:
*Zip:
Email Address:
*Home Phone:
Cell Phone:
Work Phone:
*When is a good time to call you?
*Which number?

*Are you a:

US Citizen

Permanent US resident

Documented to work in the US

Other (explain in box below)

[if other]:

LIVING SITUATION *Do you now live in Champaign County?
*Do you now work in Champaign County?
*How many people would be living in the house including you?

*Are you applying alone?
If no, name of other person:
Relationship to you:

INCOME *What is your income? [ per hour ]
*How many hours per week?
How much Annually?

*If someone else is applying with you What is their income? [ per hour ]
How many hours per week?
Have you had a steady income for the last 6 months?

How much Annually?

*Have you had a steady income for the last 12 months?

*Have you claimed bankruptcy in the last 2 years?

*Do you have outstanding judgments against you for unpaid bills?

If yes, when will these be paid off?

*Do you have any accounts or bills in "collection"?

If yes, when will these be paid off?

*Why are you interested in the Habitat Homeownership Program: