USDA/HUD HOUSING APPLICATION
Do you have any Rental Property or Business Property income? Y N
If yes, give the name and address of the renter or the business owner:
Name: _______________________________ Amount of rent of income per month: _______________
Address: _______________________________________________________________________________
ASSET INFORMATION:
Does any member of the household own any of the following types of assets?
Type of Asset
Value or Current
Name of Financial
Balance
Institution
Checking Account
Y N
Savings Account
Y N
Credit Union Shares
Y N
Stocks/Bonds
Y N
Treasury Bills
Y N
Money Market Funds
Y N
Certificate of Deposit
Y N
Rental Property
Y N
Real Estate/Mortgages/ Land Contracts
Y N
Safe Deposit Box
Y N
Deeds or Trust
Y N
Annuities
Y N
Own a Mobile Home
Y N
IRA or Keogh Account
Y N
Mutual Funds
Y N
Personal Property held for investment
Y N
Other Financial Assets
Y N
Has any household member disposed of any assets at less than fair market value during the past two years?
Yes No If yes, explain: ___________________________________________________
MEDICAL AND UNUSUAL EXPENSES:
Provide the following information for ALL household members.
Amount
Payee
Do you pay babysitting and/or dependent care
while a family member is employed?
Y N
Are you receiving Medicare Benefits?
Y N
Are you receiving Medical Assistance through the
Welfare Department?
Y N
Do you pay any medical insurance/hospitalization?
Y N
Do you have outstanding medical bills, which you
Y N
are currently paying?
Do you take prescription drugs on a regular basis?
Y N
Do you anticipate any health care related expenses
for the next 12 months, which are not covered by
health insurance?
Y N
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