Pre-screening – City of Falls Church Affordable Homeownership Program

Personal Information

Applicant Name*

First Last

Co-Applicant/Other Adult Name (if applicable)

First Last

Address*

Street Address City State Zip Code

Number of Adults in Household*

Number of Dependents in Household*

Email Address*

Home Phone

Cell Phone

Has anyone on this application ever owned residential property in the last three years?*

Yes

If "Yes" and property was owned with a spouse, are you now divorced and applying as single?

Yes

Marital Status*

Single

Married

Divorced

Widowed

Separated

Is anyone in the household disabled?*

Yes

If yes, documentation from a licensed professional will be needed.

I am or have been formally homeless*

Yes

How soon are you looking to purchase a home?*

How did you learn about this program?*

Ethnicity (must select one)*

Hispanic

Non-Hispanic

Race (select applicable—for statistical purposes only)

White

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

American Indian or Alaska Native

Other

Employment

Applicant’s Current Employer*

Number of years worked*

Address*

Street Address City State Zip Code

Co-Applicant’s/Other Adult’s Current Employer

Number of years worked

Address

Street Address City State Zip Code

Are any employers located in the limits of the City of Falls Church, Virginia?*

Yes

APPLICANT

Gross Employment Income*

Other Income Source*

CO-APPLICANT/OTHER ADULT

Gross Employment Income

Other Income Source

Total Annual Household Gross Income*

Savings Available for Home Purchase*

Certification

The applicant(s) on this form is interested in participating in the City of Falls Church Affordable Homeownership Program. I/we understand that the information provided on this pre-screening form is only a preliminary step that will be used to determine eligibility for this program.

I/we certify that all information provided is true and complete to the best of my/our knowledge and belief. I authorize the City of Falls Church and/or its designees to verify this information and to request a copy of my/our pre-approval letter from the approved Virginia Housing lender.

Applicant Signature*

Co-Applicant/Other Adult Signature

Date*

Date

Date of Birth*

Date of Birth

The City of Falls Church does not discriminate on the basis of disability in its employment practices or in the admission to, access to, or operations of its services, programs, or activities. Cindy Mester has been designated to coordinate compliance with the ADA non-discrimination requirement.