Pre-screening CITY OF FALLS CHURCH AFFORDABLE HOMEOWNERSHIP PROGRAM (CFCAHP) PRE-SCREENING FORM PLEASE FILL OUT FORM COMPLETELY Section BreakApplicant Name First Last Co-Applicant/Other Adult Name First Last Address Street Address City State Zip Code Number of Adults in HouseholdNumber of Depenents in HouseholdHome PhoneCell PhonePhone (other)Has anyone on this application ever owned residential property in the last three years? No Yes If "Yes" and property was owned with a spouse, are you now divorced and applying as single? No Yes Marital Status Single Married Divorced Widowed Separated Is anyone in the household disabled? No Yes If yes, documentation from a licensed professional will be needed.I am or have been formally homeless No Yes How soon are you looking to purchase a home?Ethnicity(must select one) Hispanic Non-Hispanic Race(please check applicable—for statistical purposes only) White Asian Black or African American Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Other EmploymentApplicant’s Current EmployerNumber of years workedAddress Street Address City State / Province / Region ZIP / Postal Code Co-Applicant’s/Other Adult’s Current EmployerNumber of years workedAddress Street Address City State / Province / Region ZIP / Postal Code Are any employers located in the limits of the City of Falls Church, Virginia? No Yes ApplicantGross Employment IncomeOther Income SourceOther Gross IncomeCo-Applicant/Other AdultGross Employment IncomeOther Gross IncomeOther Income SourceTotal Annual Household Gross IncomeSavings Available for Home PurchaseCertificationThe applicant(s) on this form is interested in participating in the City of Falls Church Affordable Homeownership Program. I/we understand that the information provided on this pre-screening form is only a preliminary step that will be used to determine eligibility for this program. I/we certify that all information provided is true and complete to the best of my/our knowledge and belief. I authorize the City of Falls Church and/or its designees to verify this information and to request a copy of my/our pre-approval letter from the approved Virginia Housing lender.Applicant Signature Reset signature Signature locked. Reset to sign again Co-Applicant/Other Adult Signature Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date of Birth MM slash DD slash YYYY Date of Birth MM slash DD slash YYYY The City of Falls Church does not discriminate on the basis of disability in its employment practices or in the admission to, access to, or operations of its services, programs, or activities. Cindy Mester has been designated to coordinate compliance with the ADA non-discrimination requirement.
