RHS-0575-NEW 504 Intake Form

504 Home Repair Loan and Grant Program

Intake Form

For more information, visit our website at: https://www.rd.usda.gov/

OMB# 0575-0172 Form RD 3550-xxxx

Exp. Date:

Please complete the following so that we may contact you about the program:

(1) Adult Household Member’s Name	(2) Social Security # (potential applicant(s) only)	(3) Check all that apply						(4) Birthdate (mm/dd/yyyy)	(5) Monthly Gross Employment Income (before deductions for taxes, insurance, etc.)	(6) Monthly Gross Income from Other Sources (e.g., child support, social security, retirement, etc.)
		Owner	Fulltime Student	Disabled	Married	Single	Divorced or Separated

(7) Names and ages of any dependents:
(8) Monthly medical expenses:	$	(9) Monthly childcare expenses:	$
(10) Monthly debt payments: (e.g., credit cards, car, etc.)	$	(11) Monthly mortgage payment: (Not including taxes and insurance)	$
(12) Annual property tax expense:	$	(13) Annual homeowner insurance expense:	$
(14) Estimated total value of retirement assets: (e.g., 401K, IRA, etc.)	$	(15) Estimated total value of Nonretirement assets: (e.g., Checking and/or Savings account(s))	$
(16) Contact phone number(s):		(17) Email address(es):
(18) Address of residence:
(19) Mailing address:
(20) List of repairs: _____________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________
Estimated cost of repairs:	$

(21) Attached is/are signed Form 3550-1 “Authorization to Release information” (one for each household member who is 18 years of age or older). By submitting these releases, I authorize Rural Development to order an infile credit report (at no cost to me) that may be used to counsel me regarding loan opportunities. Submittal of this document does not obligate me to proceed with an application. Rural Development will use the report to counsel me regarding credit issues, and to determine a potential loan amount for which I may qualify. I understand that I am requesting a pre-qualification at this time and must submit a complete application to be considered for eligibility. All property owners who are requesting assistance must sign below.

_____________________________________________ _______________________________________________

(Potential Applicant Signature) (Potential Applicant Signature)

_____________________________________________ _______________________________________________

(Potential Applicant Signature) (Potential Applicant Signature)

Instructions for Completing Request Form

1. Identify all adult persons who reside in the home you currently own and for which you are seeking repair funding.

2. Provide the social security number for each potential applicant identified in item #1.

3. Place a check in each applicable box to identify the status of each adult person that was identified in item #1.

4. Provide the birthdate of each adult person identified in item #1.

5. Provide the total gross income (before taxes or deductions) of all adults identified in item #1.

6. Provide the total amount of income from other, non-employment sources. Income may include child support, social security, alimony, retirement, etc.

7. Provide the name of dependents and their ages. For example, if you have 3 dependents residing in your household, this section would be completed as follows: Ages of dependents: Jack- 5, Jill- 9, and James-13.

8. Indicate the monthly total amount paid for any reoccurring medical expenses for applicants or dependents who are elderly or have a disability.

9. Indicate the total monthly amount paid in childcare expenses for dependents 12 years of age

or younger.

10. Provide the total debt payments you have each month for consumer debt. Include debts such as: credit cards, loans, car payments, etc. DO NOT include items such as monthly utilities, car insurance, cable, internet, phone, etc. in this section.

11. Provide the monthly cost of the mortgage without any escrow for taxes and insurance, if applicable.

12. Provide the annual cost of property taxes.

13. Provide the annual cost of property insurance.

14. Indicate the amount of assets which are in retirement accounts such as 401K, IRA, employer sponsored retirement account, etc.

15. Indicate the amount of assets which are in nonretirement accounts such as checking and/or savings accounts.

16. Provide the contact phone number(s) you preferred to be reached at such as home, cell, work, etc.

17. Provide your email address(es).

18. Provide your residential home address.

19. Provide your mailing address, if different then your home address.

20. List the home repairs for which you are seeking funding and provide an estimated total cost of these repairs.

21. Only potential applicants need to sign this intake form. All potential applicants and adult household members should sign an individual copy of Form 3550-1 “Authorization to Release information”.