NHLP Application | FAAST, Inc

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Your Information

Name of Borrower *

Email Address *

Social Security Number *

Date of Birth *

Phone Numbers

Primary Phone *

Secondary Phone

Work Phone

Are you a US Citizen? *

Yes

Primary Language?

Marital Status

ID Type *

Drivers License

State ID

ID Number *

Issuing State *

Issue Date

Expiration Date

Current Address

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

County *

How would you describe your community

Have you been at this address at least 2 years? *

Yes

Income

Are you employed? *

Yes, Full Time

Yes, Part Time

Retired

Employment/Income

Name of Employer

Position

How long have you been employed?

Monthly Income

Employment/Income 2

Name of Employer

Position

How long have you been employed?

Monthly Income

Employment/Income 3

Name of Employer

Position

How long have you been employed?

Monthly Income

Do you receive Monetary Government or Retirement Benefits? *

Yes

How Much?

Do you have any other source of Income? *

Yes

Financial Information

Do you have a Banking Account? *

Average Checking Balance *

Average Savings Balance *

Where do you bank?

Is there a CoBorrower? *

Yes No

Disability Related Information

Person with a disability *

Borrower

Coborrower

Other

Describe your disability, as defined by the ADA *

- A physical or mental inpairment that substantially limits one or more life activities, a record of such impairment, or being regarded as having such an impairment.

What assistive technology device do you plan to purchase? *

How does your disability limit your employment, education, or independence? *

How will this help you with your employment, education, or independence? *

Company you wish to purchase from *

Name of company representative assisting you *

What is the cost of equipment or modification? *

What is the amount of of money requested? *

Are you receiving funding from any other source?

Yes

Household Expenses

Living Arrangements *

Rent

Own

Live with Relative

Monthly Rent/Mortgage *

If Mortgage, Who is it with?

Balance of Mortgage?

Other Bills

Please enter monthly bill average

Utilities *

Food *

Insurance *

Prescriptions *

Telephone *

Vehicle Payment

Vehicle Insurance *

Gasoline *

Credit Cards *

Other Installment Loans

Other Expenses

Final Summary

Please Review Information below

How did you hear about the New Horizon Loan Program?

Borrower Name *

Date

The above application is submitted for the purpose of obtaining credit and all information herein is certified to be true, complete and correct. I/We authorize the FAAST, Inc to make whatever credit inquiries it deems necessary in connection with the credit application or in the course of review or collection of any credit extended in reliance on this application and to share this application and credit information with its affiliates and other lenders, which may consider my/our application for approval or purchase. I/We authorize and instruct any person, including but not limited to, all local, state, or federal government agencies, or consumer reporting agencies, to complete and furnish FAAST any information it may have or obtain in response to such credit inquiries, and agree that such information, along with this application, shall remain property of FAAST whether credit is extended or not.

Federal law requires all financial institutions to notify applicants that they will obtain, verify and record information that identifies each person who opens an account or applies for a loan. When you open an account or apply for a loan, we are now required to ask your name, address, date of birth, and other information that will allow you to be identified as the account application. In addition, we will ask to see your driver’s license or other identifying documents in order to verify this information.

In accordance with New Horizon Loan Program Manual, the FAAST New Horizon Loan Program complies with the Health Insurance Portability and Accountability Act (HIPAA) and will not disclose information regarding current and former applicants and borrowers unless otherwise required by federal/state law.

FAAST will retain all records pertinent to loan applications and loans in accordance with applicable state laws and regulations and FAAST’s record retention policies and procedures.

Should FAAST guarantee my loan and make a payment on my behalf, either partial or full, I understand that I am obligated to repay that amount of money to FAAST.

I agree that

By clicking the box, I consent to use electronic communications, electronic records, and electronic signatures rather than paper documents for the forms provided on this website.

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 of St. Lucie County, Inc. (“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).