Exit June 2017 Pre-Qualification Screening First Name Question Title * 1. First Name Last Name Question Title * 2. Last Name Email Address Question Title * 3. Email Address Phone Number Question Title * 4. Phone Number Address Question Title * 5. Address City, State and Zip Question Title * 6. City, State and Zip What is your age range? Question Title * 7. What is your age range? 18-25 26-39 40-54 55 and above Household Size(Including You) Question Title * 8. Household Size(Including You) Number of males in household and ages? Question Title * 9. Number of males in household and ages? Number of females in household and ages? Question Title * 10. Number of females in household and ages? Have you lived in Leon or Gadsden County for twelve months or more? Question Title * 11. Have you lived in Leon or Gadsden County for twelve months or more? Yes No Have you had the same job or source of verifiable income for six months or more? Question Title * 12. Have you had the same job or source of verifiable income for six months or more? Yes No 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. Question Title * 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. Yes No Are you willing to make a cash down payment of $500 towards the purchase of your home? Question Title * 14. Are you willing to make a cash down payment of $500 towards the purchase of your home? Yes No Are you willing to live on a lot selected by Habitat for Humanity? Question Title * 15. Are you willing to live on a lot selected by Habitat for Humanity? Yes No Are you able and willing to contribute 400 "sweat equity" hours? Question Title * 16. Are you able and willing to contribute 400 "sweat equity" hours? Yes No Have you owned a home within the past 3 years? Question Title * 17. Have you owned a home within the past 3 years? Yes No 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 Question Title * 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 Yes No If yes, please check your household income and write it in the space provided. Question Title * 19. If yes, please check your household income and write it in the space provided. Annual Income Monthly Income Bi-Weekly Income Weekly Income Write Income Amount Race/National Origin Question Title * 20. Race/National Origin Black/African American Caucasian Hispanic American-Indian Asian Other Marital Status Question Title * 21. Marital Status Married Single Widowed Separated Submit