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2. This form serves as a preliminary qualification assessment for the City of Moline's housing assistance programs, including: Community Housing Services, Lead Paint Abatement, Neighborhood Stabilization Program, and the Washington Square Apartments sponsored by the Department of Housing and Urban Development (HUD) and the Single Family Owner Occupied Rehabilitation (SFOOR) Program and Homebuyer assistance program sponsored by the Illinois Housing Development Authority (IHDA).
6. Personal
8. First Name*
9. Last Name*
11. Social Security #
    No dashes.
12. Daytime Phone #*
    Please include area code and no dashes.
13. Evening Phone #
    Please include area code and no dashes.
15. Marital Status*

    1. Single

    1. Married
17. Co-Applicant First Name
    Required only if married.
18. Co-Applicant Last Name
20. Co-Applicant Social Security #
    No dashes.
24. Property Information
26. Property Owner: First Name*
27. Last Name*
29. Address*
31. City*
32. State*
33. Zip*
37. Household Occupants
39. 1. First Name (Self)
40. Last Name
41. Age
43. Employment Status
44. Social Security #
    No dashes.
45. Sex
    -- Select One --MaleFemale
47. 2. First Name
48. Last Name
49. Relationship to Applicant
50. Age
52. Employment Status
53. Social Security #
    No dashes.
54. Sex
    -- Select One --MaleFemale
56. 3. First Name
57. Last Name
58. Relationship to Applicant
59. Age
61. Employment Status
62. Social Security #
    No dashes.
63. Sex
    -- Select One --MaleFemale
65. 4. First Name
66. Last Name
67. Relationship to Applicant
68. Age
70. Employment Status
71. Social Security #
    No dashes.
72. Sex
    -- Select One --MaleFemale
74. 5. First Name
75. Last Name
76. Relationship to Applicant
77. Age
79. Employment Status
80. Social Security #
    No dashes.
81. Sex
    -- Select One --MaleFemale
85. Employment/Finances
87. Employer
88. Average # Hours/Week
89. Hourly Monthly Wage
91. Please Select One Option to Qualify the Next 5 Questions:*

    1. Annually

    1. Monthly

    1. Biweekly

    1. Weekly
93. 1 - Gross Income*
94. 2 - Annual Pension
    If Applicable
95. 3 - Social Security
    If Applicable
96. 4 - Child Support
    If Applicable
98. 5 - AFDC (Public Aid)
    If Applicable
100. Assets
101. Other
103. 4506-T Request for Transcript of Tax Return
     Click here to download

     Please fill out, save to your computer, and upload completed form (see right). Form may also be printed, filled, and scanned.
104. 4506-T Request for Transcript of Tax Return
106. Zero Income Verification for Household Occupants Over the Age of 18 Claiming No Income
     Click here to download

     Please fill out, save to your computer, and upload completed form (see right). Form may also be printed, filled, and scanned.
107. Zero Income Certification
111. Housing Assistance Needed

     1. Drain Tile/Sump Pump
     2. Electrical
     3. Foundation/Concrete
     4. Gutters and Downs
     5. H/C Accessibility
     6. Heating
     7. Insulation
     8. Plumbing
     9. Roof
     10. Water/Sewer Service
     11. Windows and Siding

     Check all that apply.
112. Other, please explain.
114. The Lead-Safe Certified Guide to Renovate Right
     Click here to read guide online

     All applicants must read this document.
116. Authority for Release of Information*

     1. Agree

     1. Disagree

     By electronically signing below, you are verifing that you have read the document attached above, "The Lead Safe Certified Guide to Renovate Right." Further, you hereby authorize the City of Moline to verify your bank accounts, employment records, outstanding debts, including any present or previous mortgages, and to make other inquiries pertaining to your qualification for any City of Moline assistance from Community Development Services Programs administered by the City's Planning and Development Department. The City may make copies of this letter for distribution to any party with which you have a financial or credit relationship and such party may rely on such copy as if the same were an original. Privacy Act Notice: All information collected by the City or its assignees shall be used in determining whether you qualify as a prospective recipient of a forgivable loan or other assistance under the City of Moline's Community Housing Services Programs. Such information will not be disclosed except as required and permitted by law. By providing your electronic signature below, you understand that you do not have to provide any such information, but that failure to do so may cause your application for approval as a recipient or borrower to be delayed or rejected.
118. Electronic Signature*
     Please type your full name.
Leave This Blank:


120. 1. Receive an email copy of this form.
121. Email address

     This field is not part of the form submission.

122. Submit

* indicates a required field