Mobile Home Replacement Program & New Home Construction Grant Application

First Name:
Last Name:
Social Security Number:
Street:
City:
County:
Directions to House:
Home Phone:
Work Phone:
Best Time to Call:
Best Place to Call:
How Long Have You Lived There:		years
Do You Own or Rent:

List all household members:
Name	Age	Employer's Name	Social Security Number






List all current income for household member, above:
Name		Income Source	Amount Per Week






List all assets other than house (bank accounts, real property, boat, vehicles, snowmobile, etc.) and value:


Do you have a mortgage?
Monthly Payment:
To whom paid:
Age of mobile home:		years
Sewage Disposal:		Septic System Public Sewer
Water Supply:		Well Public Water
Are sewer and water to your home adequate?


What are your monthly debts?
To whom owed	Purpose	Amount Owed	Monthly Payment







Have you ever filed bankruptcy?
If yes, date finalized:

Conflict of Interests. Are you related to:
any staff or board member of North Country Affordable Housing?
a municipal official in the locality where your home is located?
an employee, immediate family member or staff person to a state or local elected official?
a leader or chairman of a political party at any jurisdictional level, or an immediate family member of such person?