Hurricane Relief Loan Application
Basic Information
Basic Information
LeadID
First Name
Last Name
Middle Initial
Drivers License # (do not include dashes)
Home Phone
Mobile Phone
Email
Birthdate
Mailing Street
Mailing City
Mailing State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Mailing County
Please select...
SC - York County
SC - Williamsburg County
SC - Union County
SC - Sumter County
SC - Spartanburg County
SC - Saluda County
SC - Richland County
SC - Pickens County
SC - Orangeburg County
SC - Oconee County
SC - Newberry County
SC - McCormick County
SC - Marlboro County
SC - Marion County
SC - Lexington County
SC - Lee County
SC - Laurens County
SC - Lancaster County
SC - Kershaw County
SC - Jasper County
SC - Horry County
SC - Hampton County
SC - Greenwood County
SC - Greenville County
SC - Georgetown County
SC - Florence County
SC - Fairfield County
SC - Edgefield County
SC - Dorchester County
SC - Dillon County
SC - Darlington County
SC - Colleton County
SC - Clarendon County
SC - Chesterfield County
SC - Chester County
SC - Cherokee County
SC - Charleston County
SC - Calhoun County
SC - Berkeley County
SC - Beaufort County
SC - Barnwell County
SC - Bamberg County
SC - Anderson County
SC - Allendale County
SC - Aiken County
SC - Abbeville County
LA - Winn
LA - West Feliciana
LA - West Carroll
LA - West Baton Rouge
LA - Webster
LA - Washington
LA - Vernon
LA - Vermilion
LA - Union
LA - Terrebonne
LA - Tensas
LA - Tangipahoa
LA - Saint Tammany
LA - Saint Mary
LA - Saint Martin
LA - Saint Landry
LA - Saint John the Baptist
LA - Saint James
LA - Saint Helena
LA - Saint Charles
LA - Saint Bernard
LA - Sabine
LA - Rred River
LA - Richland
LA - Rapides
LA - Pointe Coupee
LA - Plaquemines
LA - Ouachita
LA - Orleans
LA - Natchitoches
LA - Morehouse
LA - Madison
LA - Louisiana
LA - Livingston
LA - Lincoln
LA - Lasalle
LA - Lafourche
LA - Lafayette
LA - Jefferson Davis
LA - Jefferson
LA - Jackson
LA - Iberville
LA - Iberia
LA - Grant
LA - Franklin
LA - Evangeline
LA - East Feliciana
LA - East Carroll
LA - East Baton Rouge
LA - DeSoto
LA - Concordia
LA - Claiborne
LA - Catahoula
LA - Cameron
LA - Caldwell
LA - Calcasieu
LA - Caddo
LA - Bossier
LA - Bienville
LA - Beauregard
LA - Avoyelles
LA - Assumption
LA - Ascension
LA - Allen
LA - Acadia
GA - Worth
GA - Wilkinson
GA - Wilkes
GA - Wilcox
GA - Whitfield
GA - White
GA - Wheeler
GA - Webster
GA - Wayne
GA - Washington
GA - Warren
GA - Ware
GA - Walton
GA - Walker
GA - Upson
GA - Union
GA - Twiggs
GA - Turner
GA - Troup
GA - Treutlen
GA - Towns
GA - Toombs
GA - Tift
GA - Thomas
GA - Terrell
GA - Telfair
GA - Taylor
GA - Tattnall
GA - Taliaferro
GA - Talbot
GA - Sumter
GA - Stewart
GA - Stephens
GA - Spalding
GA - Seminole
GA - Screven
GA - Schley
GA - Rockdale
GA - Richmond
GA - Randolph
GA - Rabun
GA - Quitman
GA - Putnam
GA - Pulaski
GA - Polk
GA - Pike
GA - Pierce
GA - Pickens
GA - Peach
GA - Paulding
GA - Oglethorpe
GA - Oconee
GA - Newton
GA - Muscogee
GA - Murray
GA - Morgan
GA - Montgomery
GA - Monroe
GA - Mitchell
GA - Miller
GA - Meriwether
GA - McIntosh
GA - McDuffie
GA - Marion
GA - Madison
GA - Macon
GA - Lumpkin
GA - Lowndes
GA - Long
GA - Lincoln
GA - Liberty
GA - Lee
GA - Laurens
GA - Lanier
GA - Lamar
GA - Jones
GA - Johnson
GA - Jenkins
GA - Jefferson
GA - Jeff Davis
GA - Jasper
GA - Jackson
GA - Irwin
GA - Houston
GA - Henry
GA - Heard
GA - Hart
GA - Harris
GA - Haralson
GA - Hancock
GA - Hall
GA - Habersham
GA - Gwinnett
GA - Greene
GA - Grady
GA - Gordon
GA - Glynn
GA - Glascock
GA - Gilmer
GA - Fulton
GA - Franklin
GA - Forsyth
GA - Floyd
GA - Fayette
GA - Fannin
GA - Evans
GA - Emanuel
GA - Elbert
GA - Effingham
GA - Echols
GA - Early
GA - Douglas
GA - Dougherty
GA - Dooly
GA - Dodge
GA - Decatur
GA - De Kalb
GA - Dawson
GA - Dade
GA - Crisp
GA - Crawford
GA - Coweta
GA - Cook
GA - Columbia
GA - Colquitt
GA - Coffee
GA - Cobb
GA - Clinch
GA - Clayton
GA - Clay
GA - Clarke
GA - Cherokee
GA - Chattooga
GA - Chattahoochee
GA - Chatham
GA - Charlton
GA - Catoosa
GA - Carroll
GA - Candler
GA - Camden
GA - Calhoun
GA - Butts
GA - Burke
GA - Bulloch
GA - Bryan
GA - Brooks
GA - Brantley
GA - Bleckley
GA - Bibb
GA - Berrien
GA - Ben Hill
GA - Bartow
GA - Barrow
GA - Banks
GA - Baldwin
GA - Baker
GA - Bacon
GA - Atkinson
GA - Appling
FL - Washington
FL - Walton
FL - Wakulla
FL - Volusia
FL - Union
FL - Taylor
FL - Suwannee
FL - Sumter
FL - St. Lucie
FL - St. Johns
FL - Seminole
FL - Sarasota
FL - Santa Rosa
FL - Putnam
FL - Polk
FL - Pinellas
FL - Pasco
FL - Palm Beach
FL - Osceola
FL - Orange
FL - Okeechobee
FL - Okaloosa
FL - Nassau
FL - Monroe
FL - Miami-Dade
FL - Martin
FL - Marion
FL - Manatee
FL - Madison
FL - Liberty
FL - Levy
FL - Leon
FL - Lee
FL - Lake
FL - Lafayette
FL - Jefferson
FL - Jackson
FL - Indian River
FL - Holmes
FL - Hillsborough
FL - Highlands
FL - Hernando
FL - Hendry
FL - Hardee
FL - Hamilton
FL - Gulf
FL - Glades
FL - Gilchrist
FL - Gadsden
FL - Franklin
FL - Flagler
FL - Escambia
FL - Duval
FL - Dixie
FL - DeSoto
FL - Columbia
FL - Collier
FL - Clay
FL - Citrus
FL - Charlotte
FL - Calhoun
FL - Broward
FL - Brevard
FL - Bradford
FL - Bay
FL - Baker
FL - Alachua
AL - Winston
AL - Wilcox
AL - Washington
AL - Walker
AL - Tuscaloosa
AL - Tallapoosa
AL - Talladega
AL - Sumter
AL - St. Clair
AL - Shelby
AL - Russell
AL - Randolph
AL - Pike
AL - Pickens
AL - Perry
AL - Morgan
AL - Montgomery
AL - Monroe
AL - Mobile
AL - Marshall
AL - Marion
AL - Marengo
AL - Madison
AL - Macon
AL - Lowndes
AL - Limestone
AL - Lee
AL - Lawrence
AL - Lauderdale
AL - Lamar
AL - Jefferson
AL - Jackson
AL - Houston
AL - Henry
AL - Hale
AL - Greene
AL - Geneva
AL - Franklin
AL - Fayette
AL - Etowah
AL - Escambia
AL - Elmore
AL - De Kalb
AL - Dallas
AL - Dale
AL - Cullman
AL - Crenshaw
AL - Covington
AL - Coosa
AL - Conecuh
AL - Colbert
AL - Coffee
AL - Cleburne
AL - Clay
AL - Clarke
AL - Choctaw
AL - Chilton
AL - Cherokee
AL - Chambers
AL - Calhoun
AL - Butler
AL - Bullock
AL - Blount
AL - Bibb
AL - Barbour
AL - Baldwin
AL - Autauga
NC - Alamance
NC - Alexander
NC - Alleghany
NC - Anson
NC - Ashe
NC - Avery
NC - Beaufort
NC - Bertie
NC - Bladen
NC - Brunswick
NC - Buncombe
NC - Burke
NC - Cabarrus
NC - Caldwell
NC - Camden
NC - Carteret
NC - Caswell
NC - Catawba
NC - Chatham
NC - Cherokee
NC - Chowan
NC - Clay
NC - Cleveland
NC - Columbus
NC - Craven
NC - Cumberland
NC - Currituck
NC - Dare
NC - Davidson
NC - Davie
NC - Duplin
NC - Durham
NC - Edgecombe
NC - Forsyth
NC - Franklin
NC - Gaston
NC - Gates
NC - Graham
NC - Granville
NC - Greene
NC - Guilford
NC - Halifax
NC - Harnett
NC - Haywood
NC - Henderson
NC - Hertford
NC - Hoke
NC - Hyde
NC - Iredell
NC - Jackson
NC - Johnston
NC - Jones
NC - Lee
NC - Lenoir
NC - Lincoln
NC - Macon
NC - Martin
NC - Madison
NC - McDowell
NC - Mecklenburg
Mailing Zip
Are you the homeowner of the house being retrofitted?
Please select...
Yes
No
Is the house being retrofitted a Mobile Home?
Please select...
Yes
No
Emergency Contact Information
Emergency Contact #1 (Name)
Emergency Contact #1 (Phone)
Emergency Contact #2 (Name)
Emergency Contact #2 (Phone)
Primary Applicant & Co-Applicant Information
Do you have homeowner's insurance?
Yes
No
What is the total of your annual Homeowner's Insurance?
Do you live in the home being improved?
Yes
No
Years living in home
Is this a rental home?
Yes
No
If required, would you be able to provide a credit-worthy co-signer?
Yes
No
Are you providing a co-signer with this application?
Yes
No
Please fill out the information requested below and your designated co-signer will receive an email with a link to the Co-signer Application. Please have them fill out the Co-signer Application to move the loan application forward.
Co-signer first name
Co-signer last name
Co-signer email address
Co-signer's phone number
Do you now, or have you ever served in the Armed Forces?
Current or Former Service
Veteran
Service-Disabled Veteran
No military service
Are you disabled?
Please select...
Yes
No
How many persons in your home are disabled?
Total # of household members
# of household members under 18
# of household members over 62
Page 1 of 7
Improvements
What type(s) of improvement(s) are you interested in financing? (choose all that apply)
Sealing
Weatherization
Attic Floor Insulation
Roof Insulation
Wall Insulation
Floor Foundation Insulation
Insulation & Duct Repair
Other
Other - Sealing
Storm Resilience
Window Repair
Window Replacement
Doors
Garage Doors
Hurricane Shutters & Fasteners
Window Shutters
Hail Protection
Exterior Siding
Other
Other - Storm Resilience
Lighting
Interior & Exterior Light Bulbs
Skylight or Solar Tube
Other
Other - Lighting
Solar Products/Window Film
Solar Pool Heater
Solar Pool Pump
Solar Water Heater
Photovoltaic
Solar Attic Fan
Window Films & Solar Screens
Other
Other - Solar/Window
Cooling
Air Conditioning
Duct Testing & Repair
Ductwork
Programmable Thermostat
Ceiling Fans
Kitchen & Bathroom Exhaust Fans
Whole House Attic Fan
Other
Other - Heating / AC
Pool/Plumbing
Pool Pump
Plumbing
Low Flow: Toilet
Low Flow: Shower Head
Low Flow: Aerator
Septic to Sewer Conversion
Irrigation Package
Rain Water Barrel
Cistern
Sprinkler Heads
Drip Irrigation
Electric Water Heater
Gas Water Heater
Other
Other - Pool/Plumbing
Roofing
Roof Replacement
Roof Repair & Reinforcement
Roof Soffit Vent Sealing/Flashing
Reflective Roof
Reflective Paint Coating
Soffit Baffles
Flashing
Hurricane Clips/Straps/Roof Anchors
Other
Other - Roofing
Health & Safety
Drywall Repair
Electric Repair
Miscellaneous Fixtures
Mold Remediation
Water Remediation
Other
Other - Health and Safety
Disability Installations
Wheelchair Ramps
Stair Lifts
Showers
Walk-in Tubs
Grab Bars/Rails
Doorway Widening
Hallway Widening
Other
Other - Disability Installations
If applying for a Recover Loan for miscellaneous hurricane
related repairs or relief, please list below:
Page 2 of 7
Income
Employment
Who is your current Primary Employer? (
Indicate if you are self-employed, disabled, or retired
.)
Tell us about your current position at your job, including job title, or indicate "Retired" if applicable.
How many years have you been at your current job?
Please select...
< 1 yr
1-3 yrs
3-5 yrs
>5 yrs
Income
Please enter your gross monthly income earned from the following sources:
Full-Time Employment
Part-Time Employment
Net Rental Income
Child Support Income
Retirement Income
Other Monthly Income
Other Income/ Assets
Source of Other Income
i.e. disability, pension, IRA distribution, etc.
Page 3 of 7
Expenses
Please enter your average expenses below.
Use Monthly amounts unless otherwise indicated.
Home
Mortgage [IF you have a PRIVATE MORTGAGE that
does not
appear
on your credit report, please provide your private mortgage monthly payment in the box below.]
If not included on credit report.
Annual Property Tax
(if not in mortgage payment)
Electricity (average month)
Annual HOA
(If not in mortgage payment)
I have a second mortgage
Annual Homeowners Insurance
(if not in mortgage payment)
Page 4 of 7
Credit Report Authorization
Credit Check
SELF collects social security numbers solely to obtain the applicant’s credit report to evaluate their financial standing and eligibility for a SELF loan. Therefore, requesting social security numbers for this purpose is permitted as provided in Section 119.071(5)a 2.a and 6.b, Florida Statutes.
I hereby authorize SELF or its authorized agent to obtain and review my credit report. My credit report will be obtained through Equifax as SELF’s prime credit bureau resource.
Social Security Number
Loan Summary Information
SELF approves loans based on a combination of factors including the applicant's credit history and ability to repay. To help us understand your needs and make a fair determination, please answer the questions below.
How did you hear about our program?
Contractor
Family/Friend
Local Gov't agency/person
211
SELF Staff
Other non-profit
Banker
Social media
Internet Search
Digital Advertisement
Presentation/Event
Direct Mail
Brochure/Flyer
Utility Bill
Email
News outlet (TV, Radio, Digital, or Print)
Other
Contractor who referred you
Do you have any debt in collections?
Yes
No
Please explain any debt in collections (350max characters)
Do you have a private mortgage?
Yes
No
Please explain any debt in private mortgages. (350max characters)
Are you current on debt obligations right now?
Yes
No
What have you done, or plan to do, to resolve these issues? (350max characters)
Have you tried applying for a loan elsewhere?
Yes
No
What type of organization did you apply to for a loan?
i.e. bank, contractor financing, private lender, etc.
Page 5 of 7
Personal Information
Demographics
*If you do not wish to furnish the information, please indicate below.
Gender
Male
Female
Prefer not to say
Hispanic Origin
Yes
No
Prefer not to say
Race/Ethnicity
American Indian or Native American
Alaska Native
Native Hawaiian
Other Pacific Islander
Caucasian
Black or African American
Asian
Prefer not to Identify
Marital Status
Married
Separated
Widowed
Divorced
Domestic partner
Never Married
Prefer not to Identify
SELF collects demographic information for compliance with Equal Credit Opportunity Act (ECOA). You are not required to furnish this information, but are encouraged to do so.
Page 6 of 7
Upload Documents
I have my documents and am ready to upload them
I don't have my documents handy
Identification
Driver's License - Clear copy of Driver’s License(s) or other legal photo identification
Military ID - Clear copy of Military ID (if applicable)
Proof of Income
Pay Stubs - Most current 2 months’ pay-stubs and/or W-2 forms
Rental Income - Copy of Rental Agreement
Retirement Statement(s)
Social Security and/or Disability Statement(s)
Self Employed/Commission - Applicants must provide most current 2
years of tax returns (1040 forms and 1120’s when applicable) or 6 months of bank statements. (Include all pages and schedules & Profit and Loss statements.)
Contractor Quote
Contractor Quote
Mobile Home Registration/Title
Mobile Home Registration
Mobile Home Title
Home Owners Insurance
Home Owners Insurance Declaration Page
Need help uploading them?
I understand that my application will not be processed until I submit all the required documents.
You can submit your application without documents but your application will not be processed until all required documents are uploaded.
If you need help uploading your documents, please call
772-468-1818
or email
info@solarenergyloanfund.org
.
Page 7 of 7
APPLICATION AND INFORMATION SHARING NOTICE
By submitting this application, you are applying for credit with both Florida Alliance for Assistive Services and Technology, Inc. (“FAAST”) and Solar Energy Loan Fund (“SELF”). FAAST and SELF are nonaffiliated non-profit Florida corporations. Furthermore, by submitting this application, you are consenting and agreeing that these third party nonaffiliated non-profits, FAAST and SELF, are allowed to share and disclose
personally identifiable financial information and nonpublic personal information collected in this application between each other
. Your explicit permission given here is an exception as found in Section 216.15 of the Gramm-Leach-Bliley Act and the Privacy Rule found at 16 C.F.R. Part 313 (May 24, 2000)
Important Notes
This application will be valid for up to 6 months after the submission date.
If you are approved for a SELF Repair and Rebuild Loan, it is required to pick a contractor from the SELF approved network found on SELF's website.
SELF will not accept applications for improvements that are already started or have already been completed.
Incompletion of the application and requirements may delay the underwriting and closing process.
AccountID
AccountName
Contact Information