Company 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 No Primary Language? English Spanish Other Marital Status Married Unmarried (Single, Divorced, Widowed) ID Type * Drivers License State ID ID Number * Issuing State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana IAIowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Issue Date Expiration Date Current Address Address Line 1 * Address Line 2 City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana IAIowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * County * Alachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia DeSoto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Marion Martin Miami-Dade Monroe Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam St. Johns St. Lucie Santa Rosa Sarasota Seminole Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington How would you describe your community Rural Urban Suburban Have you been at this address at least 2 years? * Yes No Income Are you employed? * No 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 No How Much? Do you have any other source of Income? * Yes No Financial Information Do you have a Banking Account? * No Checking Only Savings Only Both Checking and Savings 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 No 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).