MOUNTAIN COUNTRY HABITAT FOR HUMANITY

AUTHORIZATION TO RELEASE INFORMATION

This information is to be used by Mountain Country Habitat for Humanity in determining whether you qualify as a prospective homeowner under the parameters of the program.It will not be disclosed outside the agency except as required and permitted by law.You do not have to provide this information, but if you do not, your application for approval as a prospective applicant may be delayed or rejected.The undersigned waives any requirements imposed by Federal or State law that limits the use of this information by Mountain Country Habitat for Humanity, Inc.

I/We hereby authorize Mountain Country Habitat for Humanity to verify my/our past and present employment earnings records, bank accounts, and/or character references pertaining to my/our application for housing.I/We further authorize Mountain Country Habitat for Humanity to order a consumer credit report and verify other credit information, including past and present mortgage and/or landlord references. It is understood that a copy of this form will also serve as authorization. The information that Mountain Country Habitat for Humanity obtains is only to be used in the processing of my/our application for a Habitat home.

Applicant #1:

Printed Name:_____________________________________________Date:______________________

Applicant=s Signature:_____________________________________________________________________

Social Security #:_________________________________Date of Birth:_____________________________

Applicant #2:

Printed Name:_____________________________________________Date:______________________

Applicant=s Signature:_____________________________________________________________________

Social Security #:_________________________________Date of Birth:_____________________________

Request:You are authorized to release credit and employment information to Mountain Country Habitat for Humanity for the purpose of determining need, credit, employment history and/or character references pertaining to my/our application for housing.

Part I- Verification of Present Employment

Applicant's First Date of Employment	Present Position	Probability of Continued Employment
Current Gross Base Pay (Enter Amount and Check Period)	If Overtime or Bonus is applicable, is it likely to continue?	Amount of last pay increase

Remarks (if employee was off work for any length of time, please indicate time period and reason:

PRE-QUALIFYING HOMEOWNER APPLICATION FORM

(PLEASE PRINT)

Applicant=s Name_______________________________________ Date of Birth ______/_____/_______

Co-Applicant=s Name____________________________________ Date of Birth _____/_____/________

Address:_______________________________________City__________________ Zip______________

Phone Number: Home_______________________ Work____________________Other_____________

Length of residency in Taney or Stone County: Years________________ Months__________________

Marital Status: [] Married [] Separated [] Single (Included widowed or divorced)

How many people will be living in the house? Adults (over 18)_________ Children _________

Reason you are applying for a Habitat home:

[] Sub-standard living conditions. Explain:___________________________________________________

[] Over-crowded conditions. Explain_______________________________________________________

[] Currently renting and would like to own.

Current Employer:

Applicant #1_______________________________ Phone Number_______________How Long ______

Applicant #2 ______________________________ Phone Number_______________How long _______

Name, address and phone of current Landlord:________________________________________________

_____________________________________________________________________________________

Monthly Rent: ____________________ How Long: Years_______________Months________________

Monthly take home income: (If hours vary, add last two paychecks and divide by two)

Applicant #1_________________________ Applicant #2 _______________________

Approximate monthly household bills: (Include credit card payments, car payments, child care, food, utilities, medical/insurance, cable, phone, etc.
( Do Not Include Rent.) $__________________________

FILL OUT INFORMATION ON BOTH PAGES

Return this form and a copy of all applicant=s 2004 W-2 form to:

Mountain Country Habitat for Humanity

P.O. Box 6549

Branson, MO 65615

or make an appointment to bring it by the Habitat office by calling 417-335-2015