Mississippi Housing Partnership – First Time Home Buyer Intake Form

Attention Home Buyer: Before the Partnership invites you to attend a class for first time home buyers, the Partnership must first
determine whether you meet the basic eligibility requirements of the programs. Since the Partnership’s decision to take your
application will be based solely on your responses to the following questions, the Partnership makes no warranty as to the
accuracy of the information provided herein. The acceptance of your pre-application checklist by the Partnership
representatives does not represent a commitment on the part of the Partnership to offer you a second mortgage assistance or
approval of your mortgage loan.

Attn: Hynethia J. Richards
P.O. Box 22987
Jackson, MS 39225
PH: 601-969-1895 FAX: 601-969-5300

Please Check:
American Indian/Alaskan Native
Asian/Pacifica Islander
Black Non-Hispanic
Am Indian or Al Native and White
Black or AA and White
Am Indian or Al Native & Black or AA
Other multiple race

Name: Social Security #
Address: City: State:
Home Phone: Date of Birth:
Ages and Sex of Dependents (Please enter each on a separate line) :

Place of Employment: Position:

Date of Employment: Years Employed: Hrs. per WK:

WK Ph. # Extension:
Spouse Information: Name: Social Security #

Address: City: State: Zip:
Home Phone: DoB: #Dependents: Age:
Place of Employment: Position:
Date of Employment: Years Employed: Hrs. per WK:
WK Ph. #: Extension:
Rental Information:
Number of years at present address: Beg: Date: Monthly Rent:
Landlord Name and Address:
Phone #:

Monthly Income:
 ; Client 1 Client 2 Total
Base Income (Gross) $ $ $
Other Income $ $ $
TOTAL $ $ $

Please answer the following questions: YES NO
1. Are you a first time homebuyer? (A first time homebuyer has never owned
a home or has not owned a home in the past 3 years)
2. Are you a first generation homebuyer?
3. Does your annual total household income fall with in one of the following
categories? If so, please indicate by writing your family size and income
next to the category that applies.
Your Family Size Your Total Income
1 $29,900 $
2 $34,150
3 $38,450
4 $42,700
5 $46,100
6 $49,550
7 $52,950
8 $56,350
4. Do you agree to attend a pre-purchase Workshop?
5. Do you understand that you must occupy the home you are buying as
your principal place of residence?
6. Do you understand that you must apply for a loan to purchase your new
home from a lender participating in the Second Mortgage Assistance
Program and if that loan is not approved by the Lender your
Assistance under the program will not be approved?
7. Do you agree to purchase a home within the city limits of Jackson?

Please give the name of your financial institution, type of accounts and amount of funds.

By signing the bottom portion of this form, I, the undersigned, am stating all information on this form is true. MHP
is authorized to investigate my credit report, to verify my employment and income references and to obtain such
other information, as they deem necessary. I understand that Federal law provides that a person who obtains
information from a consumer reporting agency under false pretenses shall be fined not more than $5,000 or
imprisoned not more than one year or both. I agree to allow MHP to share credit and application information with
their partner lenders as they deem necessary for the approval of my mortgage loan.

Signature: ______________________________________ Date:
Co-Applicant: ___________________________________ Date:

For Partnership use only: Eligible ( ) Ineligible ( )

Received by: _____________________________________ Date: ________________