Cuban Model Housing Form

CUBAN MODEL HOUSE APPLICATION FORM
SECTION A CLIENT INFORMATION Last Name ________________________________________________ First Name _____________________________Middle Intial_______ Present Address___________________________________________ Address of Property Location _______________________________ Home Telephhone Number -- Work Telephhone Number -- Date of Birth // ...................Month/Day/Year	HOUSE PLAN SELECTED 2 bedroom, 1 bathroom - Single House 3 bedroom, 1 bathroom - Single House Please State Nature of Property Yes No Private Dwelling Yes No Private Renting Yes No Business apart from rent: Yes No Any other use. If yes, please state ______________ Nationality_____________________ ID Number ____________________ Type: Passport Drivers License Social Security National
SECTION B PERSONAL INFORMATION Name of Spouse/ Next of Kin_______________________________________________ Applicant's Employer_______________________________________________________ Occupation________________________________________________________________ Years of Service____________________________________________ No. of Dependants_________________________________________ PLEASE NOTE : Do not complete section C, if in section A the stated nature of property is for use, apart from private Dwelling.
SECTION C FINANCIAL INFORMATION Name of Present Banker_________________________Location_____________________________________ Present Gross Salary____________________________ Allowances___________________________________ Any other source of income: Yes No
Monthly Commitments Hire Purchase/Bank Loans/Other Loan ____________________________ Rent/Mortgage ______________________________________________ Insurance __________________________________________________ Food/Clothing ______________________________________________ Utilities____________________________________________________ Vehicle Maintenance ________________________________________ Other ____________________________________________________ TOTAL EXPENCES_________________________________________	Monthly Income Salary Before Tax _________________________ Salary After Tax ___________________________ Spouse's Income__________________________ TOTAL INCOME___________________________ Monthly Surplus/Deficit Total Income - Total Expenses = _____________
DECLARATION I hereby declare that the information on this application form is correct and accurate. I agree that this declaration shall be the basis of the contract between myself and the Housing Authority of Grenada. Therefore making it legally binding on the part of both parties . Signature________________________________ Date__________________ Witness by________________________ Received by___________________________ Date_________________
Notes/Comments: For official use only Client No._______________________________ Proposed Commencement Date_____________________________ Applicable Rate__________________________ Duration of Project_________________________________________ Alterations______________________________ Total cost of Project________________________________________ Courtesy Extended_______________________ Signature____________________________________ Signature_________________________________ ..............(Marketing personnel ) ..... ....... .................... (Technical personnel)

Grenada Housing Authority

& Please fax the Cuban Model Housing Application Form to Tel: (473) 440-6683