United States Department of Agriculture- Rural Development

United States Department of Agriculture- Rural Development 504 Loan Program Pre-Application

APPLICANT INFORMATION Applicant #1 Applicant #2 Name Name

Home Phone (incl. Area Code) Date of Birth Home Phone (incl. Area Code) Date of Birth

Dependents (Not Listed by Applicant #2) Dependents (Not Listed by Applicant #1) No. Ages No. Ages

Property Address (Street. Town, Zip) Property Address (Street. Town, Zip)

Mailing Address, if different from above Mailing Address, if different from above

HOUSEHOLD INCOME Gross Monthly Income Applicant #1 Applicant #2 Wages

Pensions

VA Benefits

Social Security/SSD

Child Support

Other Benefits HEAP Fuel Assistance- Annual amount received Food Stamps- Monthly amount received Earned Income Credit- Annual amount received Unemployment Benefits- Weekly amount received Childcare- Annual expense

Rural Development is an Equal Opportunity Lender, Provider, and Employer. Complaints of discrimination should be sent to USDA, Director, Office of Civil Rights, Washington, D. C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). Revised (3.24.2008) Complete for all household members EXCEPT Applicant #1 and Applicant #2 Name Age Are you Do you want to be Annual wage Sources of Annual Source of Non- a full considered for an Income Wage Non-Wage Wage Income time adjustment to Income Income (social security, student? household income (employer) child support, etc.) for a disabling y/n condition? y/n

ASSETS 1. Do you have liquid assets (cash,stocks/bonds,CD’s) in excess of $7,500? Yes No

2. Do you own real estate other than your primary residence? Yes No

3. What is the size of your lot in acres or in square footage?

4. Can your property be subdivided? Yes No Don’t Know

HOUSING EXPENSES Mortgage Payment $ per Month Unpaid Balance (Principle & Interest only)

Other Financing Payment $ per Month Unpaid Balance (Principle & Interest only)

Homeowners Insurance Real Estate Taxes

$ per Year $ per Year

LIABILITIES List the creditor’s name, monthly payment, and balance for all outstanding debts, including auto loans, charge accounts, medical, credit cards, etc. If you pay child support and/or pay for child care, include the monthly payments. Liability(not listed above) Monthly Payment Unpaid Balance

Child Support Child Care

Rural Development is an Equal Opportunity Lender, Provider, and Employer. Complaints of discrimination should be sent to USDA, Director, Office of Civil Rights, Washington, D. C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). Revised (3.24.2008) CREDIT 1. Are your bills paid up to date? Yes No Don’t Know

2. How is your credit? Excellent Good Poor Don’t Know

3. Have you declared bankruptcy within the last 3 years? Yes No

4. Are there any outstanding judgments against you? Yes No Don’t Know

HOUSING INFORMATION 1. Does your name(s) appear on the Deed to your property? Yes No

2. Is your home located on a rented/leased lot? Yes No

3. Is your home a single family dwelling? Yes No

4. What is the age and market value of your property? Age: Market Value:

5. Does your property have an in-ground pool? Yes No

6. Briefly describe the condition of your home and list the repairs you are seeking to have done to your home.

I certify to the best of my knowledge that all of the information that I have provided is correct and accurate.

APPLICANT #1

Signature: Email Application to: Date: [email protected]

Or sent to: APPLICANT #2 Rural Development 1423 Broadway, Suite 3 Signature: Bangor, ME 04401

Rural Development is an Equal Opportunity Lender, Provider, and Employer. Complaints of discrimination should be sent to USDA, Director, Office of Civil Rights, Washington, D. C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). Revised (3.24.2008)