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
  • 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

                    Last month
                    Typical month
                    Last year
                    Formal 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
                    $__________ $__________ $__________
                    $__________ $__________ $__________
                    (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:

                            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:__________

                            reviewed by:

                            start date:

                            • Paper file established

                            • Data entered in MIS