Reclaiming Communities: Roseland Hope Homes Intake Form

Thank you for your interest in purchasing a Reclaiming Communities: Roseland Hope Home with the Hope Center Foundation. Our goal is to revitalize, rebuild, and repopulate the Roseland community on the far south side of Chicago by building 1,000 affordable homes.

Through this initiative, we aim to actualize our mission by helping residents of the Urban Chicago community to successfully transition into generational wealth through home ownership.

Instructions

Complete the intake form in its entirety by completing all the required fields. Failure to submit correct information may delay processing of your intake form.

Upon completing your intake form, please visit our website for more information and instructions to complete steps 2 through 4.

Demographics

Name

Middle Initial

Date of Birth mm/dd/yyyy

Address

Neighborhood of residence

Phone

This address will receive a confirmation email

Gender

Female Male Non-binary Transgender Other

Race

African American/Black American Indian/Alaskan Native Asian Bi-racial Caucasian/White Hawaiian/Pacific Islander Multi-racial Other

Ethnicity

Hispanic Non-Hispanic

Marital Status

Single (never married) Married living together Married living separately Widowed Separated Divorced Domestic Partner Common Law

Military Status

Active Duty Veteran Spouse of Active Duty Member Spouse of Veteran Never Served

Primary Language (the language most often spoken at home)

English Spanish Polish Chinese Arabic Other

Vocational Training/Bridge Program History

No vocational training/bridge program history Some vocational training/bridge program(s) Completed vocational training/bridge program(s)

Criminal Convictions

No Convictions Convicted of Misdemeanor(s) only Convicted of Felony(ies)

Primary Interest at Program Entry

Hope Homes Job Placement/Career Development Education/Training Digital Literacy/Computer Instruction Income Support/Public Benefits Financial Education/Counseling Other

Employment Status

Employed full time Employed full time and student Employed part time and student Unemployed and looking work Unable to work due to disability Stay-at-home caregiver or parent Retired Student Other

Occupation

In school/training at program entry?

Yes No

Household Details

For the question below, a household is 1 or more heads of household and their dependents. This may include people who don't live together (e.g. child at college, parent in nursing home and etc). People living together may not be in the same household (e.g. roommates who don't blend finances).

For the question below, if you are incarcerated or in an institution such as a rehabilitation facility or group home and do NOT pay rent, please select "Household stays for free"

Living Arrangement

House/apartment is owned by household member House/apartment is rented by household member-subsidized House/apartment is rented-unsubsidized Household stays in the house/apartment/room for free (no lease) Household is homeless (without a roof) or in a shelter

Health Insurance Status

Insured through a government program (e.g. Medicaid, Medicare, SCHIP) Private insurance through a household member's employer Private insurance (not through a household member's employer), unsubsidized Private insurance (not through a household member's employer), partially or completely subsidized No insurance at all

For the question below, estimate household income for the past 12 months. Only include wages/salaries/tips,business, interest/dividend, unemployment/disability, welfare assistance, alimony/child support, pension/retirement, regular gifts from non-household members and armed forces.

Insert your Gross Household Income $0.00

For past 12 months, earned income after tax. This ONLY includes earned income (wages, salaries, tips, etc.) Report your actual earned income over the last 12 months. Note that this is different from the later question about gross annual household income.

Insert earned income after tax $0.00

For the questions below, for the past 12 months, what is the number of full months worked? A full month refers to either (1) the calendar month or (2) any 4 continuous weeks.

Insert the number of months worked.

What is your FICO Credit Score? (If unknown, type "unknown")

Reclaiming Communities: Roseland Hope Homes Intake Form

Description

Please Fix the Following