Save my progress and resume later | Resume a previously saved form Resume Later In order to be able to resume this form later, please enter your email and choose a password. Your Email: A Password: Confirm Password: Home Journey Eligibility Assessment Please note: These are the requirements for our Home Journey Housing Counseling Program.This is NOT a loan application or a guarantee of a loan for a Habitat for Humanity of Omaha house. Please allow 60 days to evaluate your assessment questionnaire. We will contact you via email or phone with additional information after we have assessed your completed questionnaire. First Name Last Name Street City Zip Code State Phone Number Email Address Date of birth (mm/dd/yyyy) What is your gender identity? Please select... Male Female Non-binary Prefer not to say Are you currently, or have you ever been a member of the U.S. Armed Forces? Please select... Yes No What is your marital status? Please select... Single Married Divorced Widowed How many adults (18 and over) live in your household?Please select... 1 2 3 4 5 How many children (under 18) live in your household?Please select... 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 20+ Will you be applying by yourself or with a co-applicant?Please select... By myself With a co-applicant Co-Applicant Information Co-Applicant First Name Co-Applicant Last Name Co-Applicant Phone Number Co-Applicant Email Address Co-Applicant date of birth (mm/dd/yyyy) Co-Applicant gender identity Please select... Male Female Non-binary Prefer not to say Co-Applicant: Are you currently, or have ever been a member of the U.S. Armed Forces? Please select... Yes No Income Information*Proof of income will be required What is the combined gross MONTHLY income for your household? (The total amount you earn before taxes and deductions) Gross ANNUAL income for your household Enter your household's individual earner information as applicable. Individual 1 (required) Employment type:Please select... Employed by Employer Self-Employment Contract Employee Not Currently Employed Years at current employmentPlease select... Less than 1 year 1 year 2 years 3 years 4 years 5+ years Who is your current employer? Co-Applicant (if applicable) Employment type:Please select... Employed by Employer Self-Employment Contract Employee Not Currently Employed Years at current employmentPlease select... Less than 1 year 1 year 2 years 3 years 4 years 5+ years Who is your current employer? Additional Information Are you a first-time homebuyer or has it been at least 3 years since you've last owned a home?YesNo What is your bankruptcy status?Please select... Never filed bankruptcy Filed bankruptcy more than 2 years ago Filed bankruptcy within the last 2 years Have you lived in the Omaha Metro area for the past 12 months?Please select... Yes No Would you feel comfortable communicating with Habitat Omaha staff in English?Please select... Yes No What is your preferred language? Please select... Afrikaans Albanian Amharic Arabic Armenian Assamese Aymara Azerbaijani Bambara Basque Belarusian Bengali Bhojpuri Bosnian Bulgarian Burmese (Myanmar) Catalan Cebuano Chewa (Chichewa) Chin Chinese (Simplified) Chinese (Traditional) Corsican Croatian Czech Danish Dogri Dutch English Esperanto Estonian Ewe Finnish French Galician Georgian German Greek Guarani Gujarati Haitian Creole Hausa Hawaiian Hebrew Hindi Hmong Hungarian Icelandic Igbo Ilocano Indonesian Irish Italian Japanese Javanese Kachin Kannada Karen Kazakh Khmer Kinyarwanda Konkani Korean Krio Kurdish (Kurmanji) Kurdish (Sorani) Kyrgyz Lao Latin Latvian Lingala Lithuanian Luganda Luxembourgish Macedonian Maithili Malagasy Malay Malayalam Maldivian (Dhivehi) Maltese M?ori (Maori) Marathi Meitei (Manipuri, Meiteilon) Mizo Mongolian Nepali Northern Sotho (Sepedi) Norwegian Odia (Oriya) Oromo Pashto Persian Polish Portuguese Punjabi (Gurmukhi) Quechua Romanian Russian Samoan Sanskrit Scottish Gaelic (Scots Gaelic) Serbian Sesotho Shona Sindhi Sinhala Slovak Slovenian Somali Spanish Sundanese Swahili Swedish Tagalog (Filipino) Tajik Tamil Tatar Telugu Thai Tigrinya Tsonga Turkish Turkmen Twi Ukrainian Urdu Uyghur Uzbek Vietnamese Welsh West Frisian (Frisian) Xhosa Yiddish Yoruba Zulu Are you a U.S. Citizen or Permanent Resident (Green Card Holder)? YesNo Which race do you identify as? Please select... Native American Asian Black or African American Hispanic/ Latino Native Hawaiian or Other Pacific Islander White Middle Eastern/ North African Some other race Two or More Races Prefer not to say Which ethnicity do you identify as?Please select... Hispanic or Latino Not Hispanic or Latino No Response Are you an immigrant to the U.S.?Please select... Yes No Prefer not to say If you are an immigrant to the U.S. Which date did you officially immigrate to the U.S.? (if you don't remember the exact date, enter the closest date you can recall) Country of origin (Nationality)Please select... Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Central African Republic Chad Chile China Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Costa Rica Côte d’Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor (Timor-Leste) Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Fiji Finland France Gabon The Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia, Federated States of Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Macedonia Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Sudan, South Suriname Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe How did you find out about Habitat Omaha's Home Journey Counseling Program? Please select... Friend or Family Member HabitatOmaha.org Social Media Email Search: Google, Yahoo, etc Employee from Habitat Omaha Television Radio Habitat ReStore Habitat Omaha Event An Employer Other I would like to learn more about what it takes to become a homeowner. I would like to receive information and resources about homeownership. Yes, please send me more information I herby agree that all of the information I have provided is correct and accurate to the full extent of my knowledge. I understand that this questionnaire is not an application or a guarantee for homeownership through Habitat Omaha. I understand that the information provided is an eligibility assessment for the Habitat for Humanity of Omaha's Home Journey counseling program. I acknowledge and give permission to be corresponded with via email or through phone communication from the staff at Habitat Omaha. 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