Oregon IDA Application Form

Transcription

1 FOR OFFICE USE ONLY Date submitted: Program Staff: Oregon IDA Application Form Please fill out this application completely to the best of your ability. Incomplete applications will not be considered. Contact information Applicant Name: Residence Address: City: State: Zip code: Home Phone #: Mobile/Alternate Phone #: Address: Please list all household members below. ( Do not include yourself, the applicant.) Name Age Relationship Income Current Employer ( for self-employment: see next section ) Company Name Employed (month/year) From: To: City State Wage per Hour or Month (circle one) Position/Type of Work Average Number of hours worked weekly: Self Employment /Your Business ( if applicable) Business name: Started (first sales) month year Last year s gross sales: Type of business? Full time (35+/week)? Part-time? Seasonal Web address: www. Business

2 Business phone number : Business address: Calculating the Monthly Gross Income of Your Household Please write down the monthly income received per source. Try to be as accurate as possible. ADJUSTED GROSS INCOME Earned Income (per month): OTHER INCOME RECEIVED Non-Taxable Income(per month): Your Monthly Gross Income TANF Self-employment Income Food Stamps Monthly Gross Income from other members in your household currently employed or self employed Housing Assistance Gifts (from friends or family, limit on gifts is 2,500) Investment income Child Support Sub-Total A Other earned, taxable income (specify: ) Other (specify): (once a year only) Earned Income Tax Credit (EITC) Unearned Taxable Income (per month): Total SSI or SSD (Social Security Benefits) Unemployment Compensation Calculating Total Adjusted Gross Income Pensions/Annuities/IRAs (retirement income) Sub-total A Other unearned, taxable income (specify): Sub-total B Sub-Total B Total Adjusted Gross Income - 2 -

3 Calculating Your Net Worth Please fill in the chart below showing what you own (assets) and what you owe (liabilities). Assets are things you own. Assets (+) Liabilities are things you owe. Liabilities (-) Vehicle 1 Year: Vehicle 2: Year: Make: Model: Make: Model: Vehicle 1: Total debt still outstanding as of current date: Vehicle 2: Total debt still outstanding as of current date : Mileage: Mileage: Home 1: Total Home 2: Mortgage 1: Mortgage 2: Total Total Total Cash Unpaid income/property taxes CDs Unpaid child support Children s Saving CDs Credit Cards (MasterCard, VISA, AMEX) Checking account Personal line of credit Savings Account balance Medical Debts Business bank account balance Personal Debts (family, friends) Business Asset/Inventory Amount Student Loans Retirement 401k/IRA Business Debts Stocks/Bonds Other Other Total Liabilities Total Assets Net worth (assets minus liabilities) Have you ever requested a copy of your own credit report ο Yes ο No If yes, when was the last time you requested a report: Have you ever been registered on the ChekSystems? ο Yes ο No Have you ever had difficulty opening a bank account? ο Yes ο No How did you first hear about the Asset Builder IDA program? ο Friend ο IDA program participant ο Mercy Corps staff ο Internet ο News media - 3 -

4 ο A flyer or brochure ο Referred by agency ο Other (please specify) What do you plan to do with your OIDA account? ο Start a business ο Expand my current business Are you currently using any other services at Mercy Corps? ο Yes ο No If yes, please identify the service(s) Are you planning to apply for a loan through Mercy Corps Northwest s micro-enterprise loan program? ο Yes ο No Have you or any member of your household ever participated in an Individual Development Account Program? ο Yes ο No If yes, please provide the name of the organization Short Business Plan. Please fill this section out in detail with complete sentences. Feel free to attach additional sheets to better explain your business or business idea. This business plan will greatly influence whether your business will be eligible for this program. 1. Briefly describe your business. (Please include legal organization of the business). 2. What products or services will you sell? What is the demand for your products/ services? Please cite sources. 3. What is your experience with this product or service? 4. What previous business experience have you had? - 4 -

5 5. Who are your customers? (Not everyone is your customer. Be as detailed as possible.) 6. Where will your place of business be and why is this a good location for your business? (home, mall, business district, etc. Please include city and specific areas within the city). 7. What other resources have you contacted or used for help with your business? 8. What are your goals for your business this year and how do they fit with your long-term business and personal goals? Use of Funds The Oregon IDA matching savings program operates on a 3:1 match ratio, with a 1000 annual savings goal up to a maximum of three year savings period. After attending the required workshops and having your business plan approved, Mercy Corps Northwest matches every 1000 saved with IDA funds can only be used for hard assets. Inventory, rent and other monthly expenses are not covered through IDA funds. Vehicle purchases are also not eligible. How do you plan on using the money received through this program? Please be specific

6 Feel free to share any other information you think would help us in considering your application (you may another page). I certify that all the statements made on this application are true to the best of my knowledge. I understand that any misrepresentation, false or misleading statement may result in the denial of my application or permanent termination from the program. (Applicant s signature) (Date) Return to: Mercy Corps Phone: (503 ) Attn: IDA Program Staff Fax: (503) NE Hoyt St. Portland, OR Please note that the review of your application may take up to 10 business days from the time Mercy Corps Northwest receives your application. Thank you for your patience. Attention: There is a 25 nonrefundable application processing fee due at the time of enrollment if accepted into the IDA program. (Please do not send a check until you have received notification).thank you