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

If someone else is applying with you What is their income? [ per hour ]
How many hours per week?
How much Annually?
Have they had a steady income for the last 12 months?

*Have you claimed bankruptcy in the last 2 years?

*Do you have any accounts or bills that are past due, in "collection" or judgements for unpaid bills?

If yes, what is the total amount due?
Why are you interested in the Habitat Homeownership Program
*