First Name(s):
Last Name(s):
Email Address:
Phone:
Address:
City:
State:
Zip Code:
How many people live in your household?:
What is your marital status? MarriedUnmarried (single, divorced, widowed)Separated
What is your residency status? U.S. CitizenPermanent Resident
Have you lived or worked in the United States for at least the last 12 months? YesNo
Please look at the Income Chart below, find the column for the number of people in your household and look at the minimum and maximum income levels. Is your family income between the minimum and maximum?YesNo
HHI: Household Income All information presented here applies to all of the Burlington-South Burlington, VT MSA.
*Household means all related or unrelated persons who occupy a housing unit.
Is your current housing overcrowded, too expensive, or unsafe? YesNo
How many years have you lived at your current address?:
What is your monthly rent?:
If you have any of these monthly payments please enter what the payment amounts are:
Car loan payments:
Credit card payments:
Any other loan payments:
If you rent, are utilities included? YesNo
If you rent, do you receive rental assistance or is your rent determined by your income? YesNo
Are you a veteran? YesNo
Do you certify that to the best of your knowledge that the information you provided in this pre-application is accurate and complete? YesNo
