Morningside Resident Critical Home Repair Application

Homeowner First Name *

Last Name *

Co-owner First Name

Last Name

Street Number

Street Name (Choose from below)

City

State

Zip Code

Email *

Home Phone *

Cell Phone

Work Phone

Information for Government Monitoring Purposes

The following information is requested by the federal government for programs related to the purchase of homes, in order to monitor the organization’s compliance with equal credit opportunity and fair housing laws. You are not required to furnish this information, but are encouraged to do so. The law provides that a lender may neither discriminate on the basis of this information, nor on whether you choose to furnish it or not. However, if you choose not to furnish it, under federal regulations the organization is required to note race and sex on the basis of visual observation or surname. If you do not wish to furnish the information below, please check the box below.

I do NOT wish to furnish this information

What race do you identify with?

What ethnicity do you identify with?

What gender do you identify with?

Armed Forces Service History

Armed Forces Service *

I am currently serving in the Armed Forces

I previously served in the Armed Forces

I am the surviving spouse of an Armed Forces Service member

I have never served in the Armed Forces

Was Either Parent a Veteran?

Yes

No

Only Answer these if you selected "yes" to one of the previous questions

Branch of Service

Start Date

End Date

What is the status of your discharge?

Did you attend boot camp?

Yes

No

If yes, what year?

Did you serve in the Reserves?

Yes

No

Do you have a DD-214?

Yes

No

Do you go to the VA hospital?

Yes

No

If yes, for how long

Did you serve in active war?

Yes

No

What years did you serve in the armed forces?

Morningside Resident Critical Home Repair Application

Information for Government Monitoring Purposes

Armed Forces Service History

Only Answer these if you selected "yes" to one of the previous questions

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