LOAN INTAKE:
Client Household Profile
ROOF REPLACEMENT
"Foster Homeownership and Revitalize Neighborhoods"
Must be completed for all clients
Date:
Date of Birth:
Client Name (First, Middle Initial, Last):
Social Security Number:
Street Address:
City:
State:
Home or Cell Phone Number:
Email Address:
Married:
Zip:
Disabled:
Type of Rehabilitation Interested:
Job Duration:
Farm Worker: Y
N
For statistical purposes, circle or check appropriate answer as it applies:
Ethnicity: (You must select one:)
Hispanic
Non-Hispanic
Choose not to respond
Single Race:
Multi-Race:
Veteran: Y N
Gender:
Male
Household Type:
1. America Indian/Alaskan Native
7. American Indian/Alaskan Native
1. Single adult
2. Asian
and White
8. Asian and White
9. Black/African and White
10. American Indian/Alaska
Native and Black/African American
11. Other Multiple Race
2. Female-headed single parent
3. Male-headed single parent
4. Married without children
5. Married with children
6. Two or more unrelated adults
7. Other
3. Black/African American
4. Native Hawaiian/Pacific Islander
5. White
6. Choose Not to Respond
Female
For statistical purposes, please indicate highest level of education:
Doctoral or Professional Degree
Master's Degree
Bachelor's Degree
Must be completed for all clients
Associate's Degree
Postsecondary Non-Degree Award
Some College, No Degree
Date:
Co-Client Name (First, Middle Initial, Last):
High School Diploma or Equivalent
Less than High School
Date of Birth:
Social Security Number:
Street Address: check if same as above
City:
State:
Zip:
Home or Cell Phone Number:
Email Address:
Married:
Farm Worker: Y N
Veteran: Y N
Disabled:
Type of Rehabilitation Interested:
Job Duration:
For statistical purposes, circle or check appropriate answer as it applies:
Ethnicity: (You must select one:)
Hispanic
Non-Hispanic
Choose not to respond
Single Race:
Multi-Race:
1. America Indian/Alaskan Native
2. Asian
3. Black/African American
4. Native Hawaiian/Pacific Islander
5. White
6. Choose Not to Respond
7. American Indian/Alaskan Native
and White
8. Asian and White
9. Black/African and White
10. American Indian/Alaska
Native and Black/African American
11. Other Multiple Race
Gender:
Male
Household Type:
1. Single adult
2. Female-headed single parent
3. Male-headed single parent
4. Married without children
5. Married with children
6. Two or more unrelated adults
7. Other
For statistical purposes, please indicate highest level of education:
Doctoral or Professional Degree
Master's Degree
Bachelor's Degree
Associate's Degree
Postsecondary Non-Degree Award
Some College, No Degree
High School Diploma or Equivalent
Less than High School
Female
List ALL Household Members including Client and ALL sources of income for adult members of the household. Include unearned
income of minor children. Income Sources: Wages, Worker's Comp, Veteran Benefits, Unemployment, SSI, Social Security Benefits,
Retirement, Public Assistance, Military, Child Support, Alimony, Other: amounts must be broken down per category per recipient.
Name
Relationship to Client
Date of Birth
(of non applicant)
High School Student Gross Annual
Income
Y or N
Primary Source of
Income
Client
Co-Client
I hereby certify that the information given above is accurate and complete. I understand that if information I provided is
discovered to be false or misleading, my participation may be denied or terminated.
CONSENT: I/We hereby allow this Agency, its agents, employees, or its affiliates to request and obtain income
and asset information, mortgage, credit bureau and personal information pertinent to KNHS Loan Programs. I/We
allow contact to be made on my/our behalf with representatives from mortgage, attorney, collection and credit
bureau companies.
______________________________________
Printed Name
______________________________________
Printed Name
______________________________________
Printed Name
______________________________________
Signature
______________________________________
Signature
______________________________________
Signature
________________
Date
________________
Date
________________
Date
KNHS will be providing 0% loans for Deferred Maintenance Roof Program. The program guidelines allows for
7 qualified applicants. This program is available for owner-occupied and income qualified homeowners in Eastside,
Edison, Fairmont/Douglas, Northside, Stuart & Vine Neighborhoods. This activity is brought to you in partnership with
the City of Kalamazoo.
A Loan Specialist will contact you within 1-2 weeks after receiving a completed Loan Intake. Additional paperwork
will be required to verify income and eligibility.