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Community Housing Program Preliminary Qualification Form

  1. 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).
  2. Personal
  3. No dashes.
  4. Please include area code and no dashes.
  5. Please include area code and no dashes.
  6. Marital Status*
  7. Required only if married.
  8. No dashes.
  9. Property Information
  10. Household Occupants
  11. No dashes.
  12. No dashes.
  13. No dashes.
  14. No dashes.
  15. No dashes.
  16. Employment/Finances
  17. Please Select One Option to Qualify the Next 5 Questions:*
  18. If Applicable
  19. If Applicable
  20. If Applicable
  21. If Applicable
  22. Housing Assistance Needed
    Check all that apply.
  23. Authority for Release of Information*
    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.
  24. Please type your full name.
  25. Leave This Blank:

  26. This field is not part of the form submission.