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Emergency & Accessibility Loan Program Borrower Application E&A_Borrower_Application 1 of 6 09/26/2011 INSTRUCTIONS: Complete all information on this application. Please print. Use ink. Last Name First Name MI Yes No Social Security Date of Birth Dependents under 18 Other Dependents Disabled Household Household Size Move in Date Years Employed ( ) ( ) Business Phone Extension Home Phone Mailing Address Mailing Address 2 City State Zip Code The following information is requested for all borrowers by the federal government for certain types of loans related to a dwelling in order to monitor the lender’s compliance with equal credit opportunity, fair housing, and home mortgage disclosure laws. You are not required to furnish this information, but are encouraged to do so. The law provides that a lender may not discriminate on the basis of this information, or on whether you choose to furnish it. However, if you choose not to furnish the information and you have made this application in person, under federal regulations the lender is required to note ethnicity, race, and sex on the basis of visual observation or surname. If you do not wish to furnish the information, please check below. Sex Male Female Ethnicity Hispanic or Latino Not Hispanic or Latino Marital Status Married Not Married Separated Race (select 1 or more) White Asian Black or African American American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander I do not wish to furnish this information Borrower Information Clear Clear ---PAGE BREAK--- E&A_Borrower_Application 2 of 6 09/26/2011 Last Name First Name MI Social Security Date of Birth Sex Male Female Ethnicity Hispanic or Latino Not Hispanic or Latino Marital Status Married Not Married Separated Race (select 1 or more) White Asian Black or African American American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander I do not wish to furnish this information Relationship to Borrower Co-Head of Household Dependent Other Adult Spouse Income List all household members, their ages, and their estimated income (even if it is zero). Income listed should include all income which can be reasonably expected to be received during the next 12 months. Income includes, but is not limited to, the following sources. Base Pay Educational Grants Self-Employment Transfer Payment Income (Unemployment Compensation, Public Assistance, Worker’s Compensation, Disability, VA, Pensions, Social Security Benefits) Variable Income (Bonus, Overtime, Shift Pay, Commissions, Tips, Seasonal) Interest/Dividend Flexible Benefit Cash Investment Property, etc. (Rental Income, Contract for Deed Payment Income) Housing Car/Allowance Roommate Rent Child/Spousal Support Income from retirement, 401(k) and Keogh accounts Other Co-Borrower Information (Repeat for all Co-Borrowers) Household Information Clear Clear ---PAGE BREAK--- E&A_Borrower_Application 3 of 6 09/26/2011 Name of Household Member Age Source Annual Income Total Annual Household Income $ Note: Household Size listed on page 1 and the number of members listed above should match. List the cash value of assets held by all household residents. If money is owed on any item, the value listed should equal the market value of the item minus the amount that is owed. Total cash on hand, in checking and savings accounts: $ Bank Name #1 Checking Savings Bank Name #2 Checking Savings Bank Name #3 Checking Savings Bank Name #4 Checking Savings Cash value of life insurance policies. $ Securities or U.S. Savings Bonds. $ Market value of all interests in real estate, exclusive of the structure to be improved and a parcel of real property of not more than two contiguous platted lots or 160 continuous acres on which such structure is located. $ Recreational vehicles such as golf carts, snowmobiles, boats, or $ All other property, excluding household furnishings, clothing, one automobile, and real estate, equipment, supplies, and inventory used in a business. $ All land in which any resident of the household holds title and is selling on a contract-for-deed. Value in this case is defined as the outstanding principal balance expected to exist on the contract one year from the date of application. $ Total cash value of retirement, 401(k), Keogh and pension fund accounts $ Institution Name #1 Institution Name #2 Institution Name #3 Life estate value on a property other than the subject property. $ Other (e.g. additional land holdings, etc.) $ Total Assets $ Assets 0.00 Clear 0.00 ---PAGE BREAK--- E&A_Borrower_Application 4 of 6 09/26/2011 Loan History I/We currently have a Minnesota Homes Rehabilitation Loan Borrower Name Date of Loan List the outstanding balance of all loans/Mortgages/Contract for Deed on the property Bank Name Outstanding Balance Current Yes No Yes No Yes No Property Information Address Address 2 MN City County State Zip Code Building Type Single Family Manufactured Home Real Property Townhome Duplex Manufactured Home Personal Property Twinhome Condominium with common areas Condominium without common areas Mobile Home Park Yes No New Existing Year Built Number of Units Value (from current property tax statement) Category Number of Bedrooms ---PAGE BREAK--- E&A_Borrower_Application 5 of 6 09/26/2011 Other Funding Sources Please list any other Funding Sources and amounts that will be used to complete this project: (Other Loans, Grants, Local Government Incentives, etc) $ $ $ $ Total Other Funding Source Amount $ Disclosures: • Minnesota Housing Finance Agency, United States Department of Housing and Urban Development or an authorized representative shall have the right to inspect the property to be improved at any time from the date of the Rehabilitation Loan, upon giving due notice to the occupants. • The information requested in this application is legally required to determine if you qualify for participation in this Minnesota Housing program. A portion of the data requested is classified as “private data on individuals” under Minnesota Statute 462A.065. Use of data obtained is limited to that necessary for the administration and management of this program by Minnesota Housing personnel, those under contract with Minnesota Housing, and other governmental agencies when authorized by state statute or federal law. • The disclosure of your Social Security Number or Minnesota Tax Identification Number is required for participation in this Minnesota Housing program, by virtue of the Minnesota Revenue Recapture Act of 1980 (Sections 270A.01 to 270A.12 of Minnesota Statutes). Supplying these numbers could result in the application of state tax refunds to the payment of any delinquent indebtedness you may owe to Minnesota Housing under this or any other Minnesota Housing programs. These numbers may be made available to state tax authorities and state personnel involved in the collection of obligations. • Under the Minnesota Criminal Code a person who obtains funds through false representation is guilty of theft and may be prosecuted and sentenced accordingly. • 15 year Mortgage (taxed as real property): If the property ceases to be your principal residence or is sold, title is transferred or conveyed, then the full amount of the loan will be due and payable. • 10 year Mobile Home Note and Security Agreement (taxed as personal property): If, prior to the maturity of the Note, the home ceases to be your principal residence, or is sold, title is transferred or conveyed, the full amount of the loan will be due and payable. • Your ability to use any potential equity in the property will be severely restricted. Subordinations are granted only under strictly limited circumstances. Certifications: • I/We understand loan funds may not be used to pay existing debt or improvements begun or completed before the date of the loan. • I/We understand that all work contained in the Scope of Work must be completed within 120 days from the date of the mortgage. • I/We understand that for the next five years, I/We will be ineligible to receive further financing through this program (with the possible exception for an emergency situation as determined by Minnesota Housing.) • I/We certify that the statements contained in this application are true, accurate and complete to the best of my/our knowledge and belief. 0.00 ---PAGE BREAK--- E&A_Borrower_Application 6 of 6 09/26/2011 Each of the undersigned hereby acknowledge that any owner of this loan, its servicers, successors and assigns, may verify or reverify any information contained in this application or obtain any information or data relating to the loan, for any legitimate business purpose through any source, including a source named in this application or a consumer reporting agency. Signatures: All residents age 18 or over with an income must sign this application. Signature Borrower Co-Borrower Other Adult Date of Application Signature Borrower Co-Borrower Other Adult Date of Application Signature Borrower Co-Borrower Other Adult Date of Application Signature Borrower Co-Borrower Other Adult Date of Application $ Lender Estimated Loan Amount Minnesota Housing does not discriminate on the basis of race, color, creed, national origin, sex, religion, marital status, status with regard to public assistance, disability, familial status, or sexual or affectional orientation in the provision of services.