8.1 HRSR 05-04-2015 - Laserfiche WebLink

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DEMOLITION LOAN APPLICATION (Individual) I. APPLICANT INFORMATION APPLICATION DATE: Applicant Name: Street Address: City State Zip Applicant Birthdate: Applicant Social Security Number: Home Telephone: Work Telephone(s): E-mail Address: Disabled Household: Yes No Marital Status: Married Not Married Separated  Co-Applicant Name: Co-Applicant Birthdate: Co-Applicant Social Security Number: Property Address of Proposed Demolition: Elk River 55330 II. OTHER HOUSEHOLD MEMBERS EXCLUDING APPLICANT AND CO-APPLICANT NAME DOB RELATIONSHIP STUDENT SOCIAL SECURITY NUMBER (MM/DD/YY) (Child, Friend, Parent) (Y/N) ________________________ _________ _______________ ________ _________________________ ________________________ _________ _______________ ________ _________________________ ________________________ _________ _______________ ________ _________________________ ________________________ _________ _______________ ________ _________________________ Ill. INCOME INFORMATION Sources of income include but are not limited to: wages, salaries, overtime, tips, bonuses, commissions, self-employment, cash for work, regular pay for the armed forces, welfare (MFIP, GA, MSA), workers compensation, unemployment benefits, pensions, severance pay, child support, alimony, education grants, scholarships, VA student benefits, disability/social security payments, retirement benefits, death benefits, annuities, life insurance dividends, lump sum payments, net income from rental property, regular cash contributions. * Income is to be projected for the upcoming 12 months. * Include all full time, part time, sporadic, and/or seasonal income. * List separately all sources of current and anticipated income for one year following the date of the application. * All household members 18 and over receiving income must be included. 181302v1 5