Sample IDA Application

You will need to fill out an application form with more detailed information, similar to the one shown here.


Sample Potential Participant Application Form

Please note: All information requested on this application form will be kept confidential within the sponsoring organization and the IDA program's partner organizations and evaluators. Much of the personal and financial information collected on this form is necessary only for evaluative purposes.

Personal Information

Name: ___________________________ Social Sec. No.: ____ - ____ - ____
Street: ___________________________ Apt #: ________
City: ___________________________ State: ____ ZIP Code: ________
Home Phone: (____)_________ Work Phone: (____)_________
Cellphone: (____)_________ Gender: _ Female _ Male
Ethnicity:
  • African-American
  • Caucasian
  • Latino or Hispanic
  • Asian, Pacific Islander
  • Native American
  • Other (please specify: ________________)

      Highest Level of Education Completed:
      • Grade K through 5
      • Grade 6 through 8
      • Grade 9 through 11
      • High school diploma or GED
      • Attended college
      • Graduated junior college (2 year)
      • Graduated college (4 year)
      • Attended graduate school

                  Place of Residence:
                  • Urban or suburban (population of 2,500 or more)
                  • Small town or rural (population of less than 2,500)

                  How did you hear about this program?


                  Do you have any special needs the IDA staff should know about?


                  Household Information

                  "Household" includes: 1) your financial dependents (for example, your dependent children), 2) anyone you depend on financially (for example, your parents), or 3) anyone with whom you are financially interdependent (for example, your spouse or partner). Your "household" may or may not be the same as the people you live with.

                  How many adults (18 years and older) currently live in participant’s household:


                  How many children (under 18 years) currently live in participant’s household:


                  Applicant’s marital status:
                  • Single (never married)
                  • Married
                  • Separated
                  • Divorced
                  • Widowed

                    What is the primary language spoken in your household?


                    If it is not English, is English also spoken?


                    Emergency Contact Information

                    Please list a relative or friend who would definitely know how to contact you, even if you move:

                    Name: ___________________________ Phone: (____)_________
                    Street: ___________________________ Apt #: ________
                    City: ___________________________ State: ____ ZIP Code: ________

                    Income Information

                    Category
                    Last month
                    Typical month
                    Last year
                    Formal employment
                    (wages)
                    $__________ $__________ $__________
                    Self-employment
                    (selling things you make,
                    doing laundry, sewing,
                    child care, etc.)
                    $__________ $__________ $__________
                    Government assistance
                    (TANF, Food Stamps, SSI,
                    Social Security, Unemployment
                    or Veterans’ Benefit)
                    $__________ $__________ $__________
                    Pensions or
                    retirement income
                    $__________ $__________ $__________
                    Child support/
                    alimony payments
                    $__________ $__________ $__________
                    Friends or
                    family
                    $__________ $__________ $__________
                    Investment
                    income
                    $__________ $__________ $__________
                    Other
                    (please specify:
                    _____________)
                    $__________
                    $__________
                    $__________

                    Employment Information

                    Primary employment status (choose one):
                    • Employed more than full-time (overtime or more than one job, for yourself or others)
                    • Employed full-time (for yourself or others)
                    • Employed part-time (for yourself or others)
                    • Currently seeking employment
                    • Working and in school or job training
                    • Homemaker, not seeking employment
                    • Laid off, waiting for call back
                    • Disabled, not seeking employment
                    • Currently in school or job training
                    • Retired, not seeking employment

                            Employer: ___________________________ Phone: (____)_________
                            Street: ___________________________ Apt #: ________
                            City: ___________________________ State: ____ ZIP Code: ________

                            Assets & Liabilities

                            Assets and liabilities:
                            Yes
                            No

                            Do you own a vehicle(s)?



                            Value of vehicle(s):
                            $__________
                            Outstanding vehicle loan(s)
                            $__________
                            Do you own a home?



                            Value of home:
                            $__________
                            Outstanding mortgage:
                            $__________
                            Do you own a business?



                            Value of business:
                            $__________
                            Outstanding loan(s):
                            $__________
                            Do you own residential rental property or land?



                            Value of property:
                            $__________
                            Outstanding property loan:
                            $__________
                            Do you own stocks, bonds, a 401(k), or other investments?



                            Value of investments:
                            $__________
                            Do you have a checking account?



                            Amount in account:
                            $__________
                            Do you owe money to friends or family?



                            Amount you owe:
                            $__________
                            Do you have past-due household bills?



                            Amount past due:
                            $__________
                            Are you carrying a balance on credit card(s)?



                            Amount of balance(s):
                            $__________
                            Do you have outstanding student loans?





                            Outstanding loans:
                            $__________
                            Do you have outstanding medical bills?





                            Outstanding balance:
                            $__________

                            Applicant Personal Statement

                            Please explain why you are interested in participating in an IDA program. Be sure to describe the asset you would be interested in purchasing with your IDA savings.







                            How much do you think you could afford to save each month? $___________

                            Applicant Certification

                            My signature below certifies that all information provided on this application is accurate and complete to the best of my knowledge.


                            Signature: __________________________________________
                            Date: ____________

                            Applicants under age 18 must have the consent of a parent or guardian:
                            My signature below certifies that I am a parent or guardian of the minor applicant on this application and that I consent to the applicant’s participation.

                            IDA Program: __________________________________________
                            Signature: ____________________________________________
                            Date: ____________

                            Relationship to Participant: ______________________________________________________


                            For Office Use Only

                            Date received:
                            __________
                            • Application complete
                            • Interview scheduled:__________

                            Application
                            reviewed by:
                            __________

                            Participant
                            start date:
                            __________

                            • Paper file established

                            • Data entered in MIS