Neighborhood Revitalization Pre-Qualification Form

This is a pre-screening questionnaire, not a final application for Home Repair.
This form is to help determine if the Habitat for Humanity program might be right for your household. It is one step in the process of applying for a home repair.

Equal Housing Opportunity: We are pledged to the letter and spirit of U.S. policy for the achievement of equal housing opportunity throughout the nation. We encourage and support an affirmative advertising and marketing program in which there are no barriers to obtaining housing because of race, color, religion, sex, handicap, familial status or national origin.

Applicant Header

Applicant Information

Applicant Name
Applicant Address
Applicant Contact Info
Applicant
MM/DD/YYYY
Co-Applicant Header

Co-Applicant

Co-Applicant Question
Co-Applicant Information
Residency and Property Information Header

Residency and Property Information

Residency and Property Multiple Questions
Have you lived or worked in Pinellas County for at least one (1) year? *


Are you or the co-applicant the homeowner? *


Are all mortgage and property tax payments current? *



Do you have current, unsatisfied citations for code violations? *


Have you received insurance claim money for any of the repairs you are requesting assistance for? *



Do you have homeowners insurance? *


Is there a 2nd mortgage or unsatisfied lien on the property?


Is the property located in flood zones A or V? *



Is the property a mobile home? *


Financial Information Header

Financial Information

Financial Information Multiple Questions
Have you had verifiable and continuous income for at least 1 year? *


Have you ever filed for bankruptcy? *


Do you have any debt in collections? *


Do you own any other properties? *


Gross Monthly Income Header

Gross Monthly Income

List your total monthly income from applicant and co-applicant, including the income from all those 18 and older who will be living in the home. Include income from these sources: Wages (before taxes and deductions), Social Security, alimony, child support, disability, any other regular monthly income. Please list each different type of income along with the monthly amount:

Gross Monthly Income Questions 1 of 2
What was earned monthly before taxes/deductions
If N/A leave blank
If N/A leave blank
If N/A leave blank
Gross Monthly Income Questions 2 of 2
If N/A leave blank
If N/A leave blank
If N/A leave blank
Monthly Expenses Header

Monthly Expenses

List your monthly expenses, including credit cards, car payments, insurance, child care, loans such as furniture or student loans, or any other debts (do not include utilities)

Monthly Expenses Questions 1 of 2
If N/A leave blank
If N/A leave blank
If N/A leave blank
If N/A leave blank
Monthly Expenses Questions 2 of 2
Please provide total amount of other loans in dollars
Please provide total amount of other sources of expenses in dollars
Residence and Repair Information Header

Residence and Repair Information

Residence and Repair Questions




Household Information

Household Information

Household Information 1 of 2
(Do not include applicant or co-applicant in this section)
Household Information 2 of 2
Is anyone in the household 65 or older? *


Is anyone in the household active military or veteran? *


Are you on the sexual predator list or have you had a drug trafficking conviction in the last 3 years? *


Willingness to Partner with Habitat Header

Willingness to Partner with Habitat

Willingness to Partner with Habitat Question
Are you willing to make a commitment to the Habitat program, which requires that homeowner candidates earn sweat equity hours and attend a series of homeownership classes? *


Are you or members of your family available to assist with sweat equity (volunteer) hours? *


Form Submission Statement

By submitting this form, I affirm that the information on this form is true. I understand that providing false information could cause me to be disqualified from the Habitat program. I understand that someone from Habitat for Humanity will contact me with the results from this questionnaire, and that I may be invited to complete a homeowner application.

* After clicking submit you will be redirected to a thank you page, if you do not see this page your form has not been submitted. In this event please search for highlighted red entry errors*