CONTACT INFORMATION

Homeowner Name:

Co-Homeowner Name (if applicable):

Property Address:

City/State/Zip Code:

Is this your Primary Residence?  Yes No

Daytime Phone Number:

Is this: ---Home PhoneCell PhoneWork Phone

E-Mail Address:

HOUSEHOLD SIZE AND INCOME CERTIFICATION

NUMBER OF ADULTS RESIDING IN THE HOUSEHOLD:

NUMBER OF CHILDREN RESIDING IN THE HOUSEHOLD:

NUMBER OF ADULTS AND/OR CHILDREN WHO RECEIVE INCOME (from any source):

Total household income (from all household members and all income sources):

Does your total household income exceed the limits listed below?  Yes No

MORTGAGE INFORMATION

Bank/Mortgage Company Name:

Current Balance:

Monthly Payment:

Estimated amount you currently have in Savings/Checking Accounts:

Is your Mortgage:  Current Delinquent

If your mortgage is delinquent, how many months?

Reason you are seeking a Forbearance:  Job Loss Reduction in Income/Hours Other Reason (Specify below)

If the reason above is "Other", please specify the reason here:

Did the reason listed above occur as a direct result of the Covid 19 Emergency?  Yes No

CERTIFICATION AND AUTHORIZATION TO RELEASE INFORMATION

1. I/We certify that the application information provided in this application (most notably information regarding household size and income) is true and correct to the best of my/our knowledge.
2. I/We authorize Keystone Challenge Fund to provide Polk County, City of Lakeland, City of Winter Haven or any other State/Federal Funding Source with information contained in this Application (if necessary for funding purposes).
3. I/We am/are aware that this information is subject to Florida’s Sunshine laws.
4. A photographic or carbon copy of this authorization may be deemed the equivalent of the original and may be used as a duplicate original.

Please type your name below as an electronic signature.

Electronic Signature of Homeowner:

Electronic Signature of Co-Homeowner or Spouse (if applicable):