UWCS IDA Collaborative

Agency Name: ______UWSEM Pathways to Financal Success IDA Program 11. Qualified Withdrawal Request Form March 2006 IDA QUALIFIED WITHDRAWAL REQUEST FORM Today’s Date ______Program Site ID: _____

Personal Information (please PRINT)

Name: ______Social Sec. No.: _____ - ____ - ______Street: ______Apt #: ______City: ______State: ____ Zip Code: ______Home Phone: (____)______Work Phone: (____)______Cell/Pager: (____)______e-mail address: ______

Purchase Information (please PRINT)

What is your IDA asset goal? □ Home Purchase

□ Education/Job Training □ Small Business Start-up □ Small Business Expansion Please describe in detail what you plan to purchase with IDA funds (i.e., a fax machine for your business, the cost of a home purchase, tuition for school, etc.): ______Please indicate whether you have:  Graduated from financial education training: Yes No  Completed asset-specific education (homebuyer/business training/secondary ed.): Yes No  Met individually with program or partner staff about your asset purchase: Yes No  Addressed other barriers to asset purchase (credit, etc.) Yes No

Payment Information (Please PRINT

To whom should your purchase check be made out (the vendor selling the asset you are buying)? Company Name:______Company Contact: ______Street: ______Phone Number: (_____)______City: ______State: ______Zip Code: ______

Amount from IDA savings: $______

Amount from your IDA match: + $______

Other funds or resources: + $______

Total payment toward asset purchase: = $______

Total cost of asset purchase (i.e., if a home—total cost of home): $______

Modified from MIDAP Policy and Procedures Manual: Participant Forms Agency Name: ______UWSEM Pathways to Financal Success IDA Program 11. Qualified Withdrawal Request Form March 2006

Have you attached copies of….  Purchase documents (i.e., estimates, invoice, tuition bills, proof of deposit, closing cost,)  Your typed small business plan, home purchase strategy or education/training plan   After your qualified withdrawal vendor check is cut:   Program Site staff will pickup.  Mail directly to Program Site staff.

Match rate on savings: Maximum savings allowable for match: savings remaining eligible to be match date of QW savings used match used matched remaining

Total used

Applicant Certification

My signature below certifies that all information provided on this withdrawal request form is accurate and complete to the best of my knowledge. In addition, I understand that it may take up to thirty days to fill my qualified withdrawal request and cut a vendor check.

Signature: ______Date: ______

Applicants under 18 must have the consent of a parent or guardian: minors require a permanent name on the account

My signature below certifies that I am a parent or guardian of the minor applicant on this application and that I certify the information on this form is accurate and complete.

Signature: ______Date: ______Relationship to Participant: ______

______/______/______Authorized UWSEM IDA Program Representative signature Date

2 Modified from MIDAP Policy and Procedures Manual: Participant Forms Agency Name: ______UWSEM Pathways to Financal Success IDA Program 11. Qualified Withdrawal Request Form March 2006

Home Purchase Information (please PRINT)

Address of NEW home: ______City______ZIP ______

Participant’s NEW phone: ( )______- ______(or number to where follow-up calls can be placed)

3 Modified from MIDAP Policy and Procedures Manual: Participant Forms Agency Name: ______UWSEM Pathways to Financal Success IDA Program 11. Qualified Withdrawal Request Form March 2006

To be completed by Program site: Site Name/ID: ______Date received: _____/_____/_____ Form reviewed by: ______□ Form Complete □ IDA dollar amounts verified Check requested: Date: _____/_____/_____ By: ______Match Check amount: $ ______Closing Date & Lender REQUIRED for Homebuyers Closing Date: _____/_____/_____ Mortgage lender: ______Participant Credit Score at program entry REQUIRED: Report Date: _____/_____/_____ Beacon ______Emperica ______Fair Isaac ______Other (Composite) ______Participant Credit Score at time of qualified withdrawal REQUIRED: Report Date: _____/_____/_____ Beacon ______Emperica ______Fair Isaac ______Other (Composite) ______Program Site Staff Signature: ______Date: _____/_____/_____

For UWSEM Use Only Site ID: ______Date received: _____/_____/_____ UWSEM Staff reviewing form: ______□ Form Complete □ IDA dollar amounts verified Withdrawal: □ Approved □ Denied Reason(s) for denial: ______Source of Funds Information: Total Asset Purchase: $ ______Participant Savings: $ ______Total Match (Rate : ) $ ______(Total Match must equal sources for match funds identified below:) TANF Funds: $ ______AFIA Funds: $ ______MSHDA Funds: $ ______Private Funds: $ ______Source(s) of Private Match: ______Additional Match: $ ______Source(s): ______Check requested: Date: _____/_____/_____ By: ______Match Check amount: $ ______Check sent/ picked up: Date: _____/_____/_____

For UWSEM Use Only RCO Signature ______Date: _____/_____/_____

4 Modified from MIDAP Policy and Procedures Manual: Participant Forms