First Name

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* 1. First Name

Last Name

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* 2. Last Name

Email Address

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* 3. Email Address

Phone Number

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* 4. Phone Number

Address

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* 5. Address

City, State and Zip

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* 6. City, State and Zip

What is your age range?

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* 7. What is your age range?

Household Size(Including You)

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* 8. Household Size(Including You)

Number of males in household and ages?

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* 9. Number of males in household and ages?

Number of females in household and ages?

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* 10. Number of females in household and ages?

Have you lived in Leon or Gadsden County for twelve months or more?

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* 11. Have you lived in Leon or Gadsden County for twelve months or more?

Have you had the same job or source of verifiable income for six months or more?

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* 12. Have you had the same job or source of verifiable income for six months or more?

Do you have a housing need? Examples include: living in substandard housing conditions, rent payments exceed 30% of your monthly gross income, overcrowded living conditions, or presently living in a transitional housing situation.

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* 13. Do you have a housing need? Examples include: living in substandard housing conditions, rent payments exceed 30% of your monthly gross income, overcrowded living conditions, or presently living in a transitional housing situation.

Are you willing to make a cash down payment of $500 towards the purchase of your home?

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* 14. Are you willing to make a cash down payment of $500 towards the purchase of your home?

Are you willing to live on a lot selected by Habitat for Humanity?

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* 15. Are you willing to live on a lot selected by Habitat for Humanity?

Are you able and willing to contribute 400 "sweat equity" hours?

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* 16. Are you able and willing to contribute 400 "sweat equity" hours?

Have you owned a home within the past 3 years?

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* 17. Have you owned a home within the past 3 years?

Does your household income meet the income criteria below based on household

(Gross income refers to your entire annual household income before taxes)

1 Person: $14,150 - $37,750
2 People: $16,460 - $43,150
3 People: $20,780 - $48,550
4 People: $25,100 - $53,900
5 People: $29,420 - $58,250
6 People: $33,740 - $62,550
7 People: $38,060 - $66,850
8 People: $42,380 - $71,150

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* 18. Does your household income meet the income criteria below based on household

(Gross income refers to your entire annual household income before taxes)

1 Person: $14,150 - $37,750
2 People: $16,460 - $43,150
3 People: $20,780 - $48,550
4 People: $25,100 - $53,900
5 People: $29,420 - $58,250
6 People: $33,740 - $62,550
7 People: $38,060 - $66,850
8 People: $42,380 - $71,150

If yes, please check your household income and write it in the space provided.

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* 19. If yes, please check your household income and write it in the space provided.

Race/National Origin

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* 20. Race/National Origin

Marital Status

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* 21. Marital Status

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