Name

Address

Loan Amount Requested

List all household members

Name

Relation

Age

1.

2.

3.

4.

5.

6.

7.

List all loans, other than City Loan, that are planned

Primary Loan

Additional Loans Anticipated

Lender

Lender

Loan Officer and Phone

Loan Officer and Phone

Adjustable _____            Fixed Rate ______

Months      _____            Interest       ______

Adjustable _____            Fixed Rate ______

Months      _____            Interest       ______

Do you own any

 residential Property?          Yes ___  No ___

Date Unit occupied:

APPLICANT CERTIFICATION: I/We hereby certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct as of the date indicated below.  I/We understand that I/we must qualify under the Program Guidelines as well as meet any Lender's financing criteria, and that I/we may not only be disqualified but may be subject to civil or criminal penalties if the information shown above is not accurate.  (All persons to appear on the title to the property must execute this form below.)

By:

Print Name

Date:

By:

Print Name

Date: