Pre-Application Information Survey

Your contact information:
Full name:	* required
Email address:
Telephone number:	* required
Address:
City:
State:
Zip code:
Your current housing:
Have you lived in York County at least 2 years?	No Yes
Have you worked in York County at least 2 years?	No Yes
Have you owned a home within the last 2 years?	No Yes
Have you declared bankruptcy within the last 2 years?	No Yes
If you were selected to live in a Habitat house, how many people would be living with you (include yourself, spouse. boyfriend/girlfriend, children, parents, etc.)?	0 1 2 3 4 5 6 7 8 other
Your MONTHLY income: The area below is used to calculate your total MONTHLY income.  Fill in the blanks if you receive the following:
Adult #1 monthly income (before taxes):
Adult #2 (if applicable) monthly income (before taxes):
Adult #3 (if applicable) monthly income (before taxes):
Social Security (including SSI):
Disability:
Child support:
Please include any other monthly income:
Your MONTHLY expenses: The area below is used to calculate your total MONTHLY expenses.  Fill in the blanks if you pay the following:
Current rent:
Auto loan:
Student Loan:
Credit card #1:
Credit card #2:
Medical collection #1:
Medical collection #2:
Please include any additional payments that you make monthly (excluding utilities):
Refer a friend:
Name and phone number:
Click Submit when finished -------->