<p> 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: _____</p><p>Personal Information (please PRINT)</p><p>Name: ______Social Sec. No.: _____ - ____ - ______Street: ______Apt #: ______City: ______State: ____ Zip Code: ______Home Phone: (____)______Work Phone: (____)______Cell/Pager: (____)______e-mail address: ______</p><p>Purchase Information (please PRINT) </p><p>What is your IDA asset goal? □ Home Purchase</p><p>□ 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</p><p>Payment Information (Please PRINT</p><p>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: ______</p><p>Amount from IDA savings: $______</p><p>Amount from your IDA match: + $______</p><p>Other funds or resources: + $______</p><p>Total payment toward asset purchase: = $______</p><p>Total cost of asset purchase (i.e., if a home—total cost of home): $______</p><p>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</p><p>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.</p><p>Match rate on savings: Maximum savings allowable for match: savings remaining eligible to be match date of QW savings used match used matched remaining</p><p>Total used </p><p>Applicant Certification</p><p>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.</p><p>Signature: ______Date: ______</p><p>Applicants under 18 must have the consent of a parent or guardian: minors require a permanent name on the account</p><p>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.</p><p>Signature: ______Date: ______Relationship to Participant: ______</p><p>______/______/______Authorized UWSEM IDA Program Representative signature Date</p><p>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</p><p>Home Purchase Information (please PRINT)</p><p>Address of NEW home: ______City______ZIP ______</p><p>Participant’s NEW phone: ( )______- ______(or number to where follow-up calls can be placed)</p><p>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</p><p>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: _____/_____/_____ </p><p>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: _____/_____/_____</p><p>For UWSEM Use Only RCO Signature ______Date: _____/_____/_____ </p><p>4 Modified from MIDAP Policy and Procedures Manual: Participant Forms </p>