Christmas In October Application

"*" indicates required fields

Applicant Information

Name*

First Middle Last

Email*

Best number to reach you*

Employer*

Employer's Address*

Position Title*

Business Phone

Applicant's Date of Birth*

Have you previously submitted an application to Christmas in October?*

Yes

Have you applied to any other organization for either a loan or a grant to repair your home?*

Yes

If YES, please indicate the organization.

If your home were selected, would you see yourself and/or your family members helping the volunteers accomplish the repairs to your home?

Yes

If NO, why?

Do you or anyone in your home have physical disabilities which we should be aware of in assessing the repairs to your home?

Yes

If YES, please describe.

Property Information

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date Property was Acquired

Original Purchase Price

Amount of Existing Liens

Year Built

# Bathrooms

# Bedrooms

Homeowner's Insurance Company

Policy #

Income & Housing Expense Information

Gross Monthly Income (s include SSI, investments, child support, public assistance, etc.)

Monthly Housing Expenses (include utilities, insurance, taxes, etc.)

Total Value of Assets (physical items such as machinery, property, raw materials and inventory, and intangible items like patents, royalties and other intellectual property.)

Total liabilities (items borrowed or owed such as loans, mortgages, deferred revenues, and bonds)

Requested Repairs

Please outline needed repairs.*

Applicant Certification

1. I/We understand that Christmas in October is a volunteer program and therefore no guarantee of materials or workmanship is provided.
2. I/We completed an application containing personal and financial information including: employment, income, occupancy status, etc. I/We certify that all of the information is true and complete. I/We made no misrepresentations in the application or other documents, nor did I/We omit any pertinent information. 3. I/We hereby authorize the City of Chula Vista to verify my/our past and present employment earnings records, bank accounts, stock holdings, and any other asset balances that are needed to process my application. 4. I/We further authorize the City of Chula Vista to order a consumer credit report and verify other credit information, including past and present mortgage and landlord references. 5. I/We understand and agree that Christmas in October reserves the right to request any additional information necessary to complete the request and verify the information provided on the application with the employer, creditor, or financial institutions. 6. I/We fully understand that it is a Federal crime punishable by fine, imprisonment or both to knowingly make any false statements when applying for this Program, as applicable under the provisions of Title 18, United States Code, Section 1014.

Date*

Upload Your Income and Expense Information*

Please include...(this needs to be completed.)

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