The undersigned applicant applies for a Habitat home in Wood County, Ohio and a no-interest loan to finance the purchase price of the home.  Applicant authorizes the Habitat for Humanity of Wood County, Inc., to evaluate applicant’s actual need for a Habitat home, ability to repay the loan and other expenses of home ownership, and willingness to participate in the Habitat program.  The evaluation will include personal visits, a credit check, and contact of references, and will normally include requests for additional information relating to program eligibility (such as proof of child custody, verification of employment, and a background check conducted by law enforcement authorities).

The applicant authorizes the Wood County Habitat for Humanity, Inc., to contact and obtain information regarding the applicant’s program eligibility, including from the references the applicant has provided, current and former employers, neighbors, relatives, credit reporting agencies, financial institutions and other creditors, public utilities, landlords, insurance companies, hospitals, physicians, legal representatives, state employment offices, social security offices, federal, state or local welfare food stamp offices, pubic authorities who can provide proof of child custody arrangements, and law enforcement authorities, and the applicant specifically releases from liability for disclosure all such parties providing confidential information to the Habitat for Humanity of Wood County, Inc.

Habitat for Wood County, Inc., will retain the applicant’s submitted application and all confidential information obtained during the application evaluation process as confidential information, subject to disclosure only to the Habitat for Humanity of Wood County, Inc., and then only as a confidential submission, or to a court or administrative agency but only if required by the order of such court or administrative agency.  The original or copy of the application submitted by the applicant and any additional information obtained under this authorization and release will be retained by the Habitat for Humanity of Wood County, Inc., even if the application is not approved.

Applicant’s signature                                                            Date                                          

Co-applicant’s signature                                                      Date