We’ve Built 388 Habitat Pinellas Homes for 1014 Children and Funded 348 Homes Overseas.

Pre-Qualification Questionnaire

This is a pre-screening questionnaire, not a final application for homeownership. This form is to help determine if the Habitat for Humanity program might be right for your household. It is one step in the process of applying for a home.

Equal Housing Opportunity: We are pledged to the letter and spirit of U.S. policy for the achievement of equal housing opportunity throughout the nation. We encourage and support an affirmative advertising and marketing program in which there are no barriers to obtaining housing because of race, color, religion, sex, handicap, familial status or national origin.

Homeowner Pre-Qualification Form
First Name:
Middle Initial:
Last Name:
Zip Code:
Daytime Phone:


1. Yes No Have you lived or worked in Pinellas County for at least 1 year?
2. Yes No Have you had the same job or verifiable income for 12 months or more?
3. Yes No Have you ever filed for bankruptcy?
3a. Yes No If yes, has it been discharged for at least 12 months?

4. If approved, how many people would be living in the Habitat home including yourself?

5. Please provide the names and ages of those who will be living with you:
6. Yes No Are you willing to make a commitment to the Habitat program, which requires that homeowner candidates earn sweat equity hours and attend a series of homeownership classes?
7. How did you hear about Habitat for Humanity's program?
8. List your total monthly income, including the income from all those 18 and older who will be living in the home. Include income from these sources: Wages (before taxes and deductions), Social Security, alimony, child support, disability, food stamps, any other regular monthly income. Please list each different type of income along with the monthly amount:
$ Wages (what you earn monthly before taxes/deductions)
$ Social Security
$ Alimony
$ Child Support
$ Disability
$ Food Stamps
$ Other Income Sources | Please Specify:
9. List your monthly expenses, including credit cards, car payments, insurance, child care, loans such as furniture or student loans, or any other debts(do not include utilities).
$ Credit Cards
$ Car Payments
$ Insurance
$ Alimony / Child Support
$ Student Loans
$ Other Loans | Please Specify:
$ Other Expenses (do not include utilities) | Please Specify:
10. Yes No Do you have any collections?
If yes, give us an estimate of the amounts:
10a.Non-Medical $
10b.Medical $
11. Yes No Are you on the sexual predator list or have you had a drug trafficking conviction in the last 3 years?

By submitting this form, I affirm that the information on this form is true. I understand that providing false information could cause me to be disqualified from the Habitat program. I understand that someone from Habitat for Humanity will contact me with the results from this questionnaire, and that I may be invited to complete a homeowner application.