You will need to fill out an application form with more detailed information, similar to the one shown here.
Sample Potential Participant Application Form
Please note: All information requested on this application form will be kept confidential within the sponsoring organization and the IDA program's partner organizations and evaluators. Much of the personal and financial information collected on this form is necessary only for evaluative purposes.
Personal Information
| Name: ___________________________ | Social Sec. No.: ____ - ____ - ____ |
| Street: ___________________________ | Apt #: ________ |
| City: ___________________________ | State: ____ ZIP Code: ________ |
| Home Phone: (____)_________ | Work Phone: (____)_________ |
| Cellphone: (____)_________ | Gender: _ Female _ Male |
Ethnicity:
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Highest Level of Education Completed:
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Place of Residence:
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How did you hear about this program?
Do you have any special needs the IDA staff should know about?
Household Information
"Household" includes: 1) your financial dependents (for example, your dependent children), 2) anyone you depend on financially (for example, your parents), or 3) anyone with whom you are financially interdependent (for example, your spouse or partner). Your "household" may or may not be the same as the people you live with.
How many adults (18 years and older) currently live in participant’s household:
How many children (under 18 years) currently live in participant’s household:
Applicant’s marital status:
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What is the primary language spoken in your household?
If it is not English, is English also spoken?
Emergency Contact Information
Please list a relative or friend who would definitely know how to contact you, even if you move:
| Name: ___________________________ | Phone: (____)_________ |
| Street: ___________________________ | Apt #: ________ |
| City: ___________________________ | State: ____ ZIP Code: ________ |
Income Information
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Category
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Last month
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Typical month
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Last year
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| Formal employment (wages) |
$__________ | $__________ | $__________ |
| Self-employment (selling things you make, doing laundry, sewing, child care, etc.) |
$__________ | $__________ | $__________ |
| Government assistance (TANF, Food Stamps, SSI, Social Security, Unemployment or Veterans’ Benefit) |
$__________ | $__________ | $__________ |
| Pensions or retirement income |
$__________ | $__________ | $__________ |
| Child support/ alimony payments |
$__________ | $__________ | $__________ |
| Friends or family |
$__________ | $__________ | $__________ |
| Investment income |
$__________ | $__________ | $__________ |
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Other
(please specify: _____________) |
$__________
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$__________
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$__________
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Employment Information
Primary employment status (choose one):
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| Employer: ___________________________ | Phone: (____)_________ |
| Street: ___________________________ | Apt #: ________ |
| City: ___________________________ | State: ____ ZIP Code: ________ |
Assets & Liabilities
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Assets and liabilities: |
Yes |
No |
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| Do you own a vehicle(s)? | Value of vehicle(s): $__________ Outstanding vehicle loan(s) $__________ |
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| Do you own a home? | Value of home: $__________ Outstanding mortgage: $__________ |
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| Do you own a business? | Value of business: $__________ Outstanding loan(s): $__________ |
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| Do you own residential rental property or land? | Value of property: $__________ Outstanding property loan: $__________ |
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| Do you own stocks, bonds, a 401(k), or other investments? | Value of investments: $__________ |
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| Do you have a checking account? | Amount in account: $__________ |
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| Do you owe money to friends or family? | Amount you owe: $__________ |
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| Do you have past-due household bills? | Amount past due: $__________ |
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| Are you carrying a balance on credit card(s)? | Amount of balance(s): $__________ |
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| Do you have outstanding student loans? |
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Outstanding loans: $__________ |
| Do you have outstanding medical bills? |
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Outstanding balance: |
Applicant Personal Statement
Please explain why you are interested in participating in an IDA program. Be sure to describe the asset you would be interested in purchasing with your IDA savings.
How much do you think you could afford to save each month? $___________
Applicant Certification
My signature below certifies that all information provided on this application is accurate and complete to the best of my knowledge.
Signature: __________________________________________
Date: ____________
Applicants under age 18 must have the consent of a parent or guardian:
My signature below certifies that I am a parent or guardian of the minor applicant on this application and that I consent to the applicant’s participation.
IDA Program: __________________________________________
Signature: ____________________________________________
Date: ____________
Relationship to Participant: ______________________________________________________
For Office Use Only
| Date received: __________
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Application Participant
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