Ashley Intake - MAKING PHILADELPHIA BETTER BLOCK BY BLOCK

Primary applicant

First Name

Middle Name

Last Name

Date of Birth

SSN

Phone

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Previous Address (If not at current address for 2 years)

Address Line 1

Address Line 2

City

State

Zip Code

Marital Status:

Highest Level of Education

Secondary applicant

If there is not a secondary applicant, please go to the NEXT STEP.

First Name

Middle Name

Last Name

Date of Birth

SSN

Phone

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Previous Address: (If not at current address for 2 years)

Address Line 1

Address Line 2

City

State

Zip Code

Marital Status

Highest Level of Education

Household

Family/Household Size

How many dependents in household?

Ages of Dependents

List ages in this box separated by a comma.

Are there any household members over the age of 18 that will be living in the home?

If yes, please list their relationship and monthly income.

Monthly Income

Housing

If renting:

Do you currently own a home?

If NO: have you owned a home within the past 3 years?

Employment

Are you currently employed with the City of Philadelphia? *

If YES, please provide your payroll number:

Current employer information (please provide at least a 2 year history)

Current Employer Name

Phone

Start Date

Current Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Title

Annual Salary

Pay Frequency

HR Contact Information

Secondary employer information (If applicable)

Secondary Employer Name

Phone

Start Date

End Date

Secondary Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Title

Annual Salary

Pay Frequency

HR Contact Iformation

Previous employer information (if not at current employer for 2 years)

Previous Employer Name

Phone

Start Date

End Date

Previous Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Title

Annual Salary

Pay Frequency

HR Contact Information

Previous employer information (if not at above employer for 2 years)

Previous Employer Name

Phone

Start Date

End Date

Previous Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Title

Annual Salary

Pay Frequency

HR Contact Information

Are you self-employed?

If yes complete below

Other Gross Monthly Income
Please provide monthly amounts. You must complete the first line of each column. If you do not have that type of income type 0

Retirement/Pension

Retirement/Pensions

If you do not have this type of income type 0

Retirement/Pensions

Social Security/Disability

If you do not have this type of income type 0

Social Security/Disability

Child Support/Alimony

If you do not have this type of income type 0

Child Support/Alimony

Other Income

If you do not have this type of income type 0

Other Income

Total Income All Sources

$0.00

Demographic Information

The purpose of collecting this information is to help ensure that all applicants are treated fairly and that the housing needs of communities and neighborhoods are being fulfilled. You are not required to answer the questions below. Responses to these questions are voluntary - you may check "Decline to State." There will be no impact on your application based on your selection of these answers. The information provided below will be kept confidential.

Gender

Military Status

Ethnicity

Disability

Race

Affidavit and Authorizations

I hereby certify that all information I have provided above is honest and complete. I understand that all documentation I provide throughout this process must be submitted truly and accurately in an unaltered state. The undersigned further understands that providing false representations herein constitutes an act of fraud. False, misleading, or incomplete information may result in the applicant’s termination in the Turn the Key Initiative.

Check here

I hereby authorize Philadelphia Housing Development Corporation (PHDC) permission to obtain a copy of a tri-merge consumer credit report on my behalf. I understand that my credit report will be obtained to be used solely for the use of the Turn the Key Initiative housing counseling to evaluate homebuying readiness. I understand this information may only be shared with other agencies that have a direct connection with the processing of my homebuying process in conjunction with Turn the Key.

Check here

I hereby authorize Philadelphia Housing Development Corporation (PHDC) permission to contact my past and current employers to verify the status of my employment, dates of employment, wages and earnings, and any other pertinent information needed to assess my employment and income qualifications as it relates to a mortgage.

Check here

I hereby consent to release of information to third parties and/or my information to be released to PHDC as it relates to and is necessary to the counseling services received by PHDC or an affiliate.

So long as you have not opted-out, we may disclose some or all of the information that we collect, as described above, to your creditors or third parties where we have determined that it would be helpful to you, would aid us in counseling you, or is a requirement of grant awards which make our services possible.

We may also disclose any nonpublic personal information about you or former customers to anyone as permitted by law (e.g., if we are compelled by legal process).

Within the organization, we restrict access to nonpublic personal information about you to those employees who need to know that information to provide services to you. We maintain physical, electronic and procedural safeguards that comply with federal regulations to guard your nonpublic personal information.

Please check one of the following:

Check here to consent
Check here to opt out

Name

Signature

Clear Signature

Date

Name

Signature

Clear Signature

Date

Please upload the followwing supporting documents. Please ensure that none of your files are larger than 8MB. Missing documents or an incomplete form may result in a delay to your process.

Photo ID

Click or drag a file to this area to upload.

Supply in jpg or png format

Upload all of the following that apply: Paystubs, Federal Tax returns for the last 2 years, W2s for the last 2 years, Bank Statements for the last 2 months, Other income such as Alimony, Social Security, Pensions, etc.

Proof of Income: Paystubs last 30 days

Click or drag files to this area to upload. You can upload up to 4 files.

Proof of Income: Federal Tax returns last two years

Click or drag files to this area to upload. You can upload up to 4 files.

Proof of Income: W2s for the last two years

Click or drag files to this area to upload. You can upload up to 4 files.

Proof of Income: Bank Statements for the last two years

Click or drag files to this area to upload. You can upload up to 4 files.

Proof of Income: Other

Click or drag files to this area to upload. You can upload up to 6 files.

This could be alimony, social security, pensions, retirement, child support, etc.

To be completed by each Household Member 18 or older with zero income. Please download the form from this link: Zero Intake Form Next have each member of the household with Zero Income complete that form (one form per person with Zero Income). Then upload the completed and signed form(s) below.

Certification of Zero Income

Click or drag files to this area to upload. You can upload up to 6 files.

Please upload all forms completed for members of the household 18+ with Zero Income.

Upload Certificate of Completion for the Webinar.

Click or drag a file to this area to upload.