1. Housing Kitsap
Mutual Self-Help Housing
Program Application
Minimum qualifications for eligibility include: Two (2) years of
verifiable employment in the same industry, decent credit, and a
verifiable income source that shows an annual earnings of
approximately $30,000 a year or more. For self-employment, please
show two (2) years of tax returns that include a schedule C.
Page 1 of 2
Applicant Name Cell Phone Work Phone Email address
( ) ( )
Physical Address City, State Zip
Mailing Address (if different from above) City, State Zip
Employer / Position / Start Date Average Monthly Pay
$ /Month
Yrs./Mos Employed in this line of
work or Industry
Co-Applicant Name Primary Phone
( )
Applicant Married? Co-Applicant Married?
YES  NO  YES  NO 
Employer / Position / Start Date Average Monthly Pay
$ /Month
Yrs./Mos Employed in this line of
work or Industry
Additional monthly Child Support DSHS Social Security Disability L&I Retirement Other_________
Income you receive: $ $ $ $ $ $ $
Household Size Adults_____ Children______ Monthly Childcare Expenses: $____________
Rent Pymt $______/Mo Move in Date? _______ Renting from Family: YES NO Section 8 Voucher Holder? YES NO
Are you willing to contribute an average of 30 labor hours per week until your home is complete? YES  NO 
Volunteers may be used to help with a portion of this requirement.
Is there anything that might prohibit your household from contributing the weekly required labor hours? YES  NO 
You should receive communication confirming that you have been placed on the Waitlist. If you do not receive this within 45 days of
your application, please call (360) 535-6139. IT IS YOUR REPONSIBILITY TO KEEP US INFORMED OF ANY CHANGES.
I certify that the above information is true and correct to the best of my knowledge.
_____________________________________ ____________ ___________________________________ ______________
Applicant Signature Date Co-Applicant Signature Date
SOCIAL SECURITY NUMBER ________________________ SOCIAL SECURITY NUMBER ______________________
DATE OF BIRTH _____________________ DATE OF BIRTH____________________
The following information is requested by the Federal Government in order to monitor our compliance with Federal Laws to help ensure that we do not discriminate
against you based on your ethnicity, race, or gender. You are not required to provide this information, but if you choose not to, we are required by law to make our best
guess, based on our visual observation or your surname.
APPLICANT  I do not wish to furnish this information CO-APPLICANT  I do not wish to furnish this information
Race:  American Indian  Asian  Black or  Native Hawaiian or
or Alaska Native African American other Pacific Islander
 White
Race:  American Indian  Asian  Black or  Native Hawaiian or
or Alaska Native African American other Pacific Islander
 White
Ethnicity:  Hispanic or Latino  Not Hispanic or Latino Ethnicity:  Hispanic or Latino  Not Hispanic or Latino
Sex:  Female  Male Sex:  Female  Male
How did you hear about us?  Friend Self-Help Owner  Website  Other Agency  Flyer/Brochure
 Employer  Community Outreach Event  Vehicle Sign  Self-Help Property Sign  Newspaper  Other_____
Please number in order the
area(s) you will consider living:
All Kitsap Co. Locations___
Port Orchard ____
Silverdale ____
Poulsbo_____
Kingston ____
All Mason Co. Locations ___
Are you interested in Acq. Rehab.
Homeownership? YES  NO


2. Housing Kitsap Page 2 of 2
Mutual Self-Help Housing Program Application
CREDIT PULL AUTHORIZATION
I/We hereby authorize Housing Kitsap to verify my/our past and present employment earnings records, bank accounts, retirement
accounts and other asset balances needed to process my/our mortgage application. I/We further authorize Housing Kitsap to order a
credit report and verify other credit information, including past and present landlord references. It is understood that a photocopy of
this form will also serve as authorization. The information obtained by Housing Kitsap is only to be used in the processing of my/our
application for a mortgage loan. Pre-qualified applications will be maintained on file for 365 days unless placed in a building group
that exceeds this duration.
_____________________________________ ____________ ___________________________________ ______________
Applicant Signature Date Co-Applicant Signature Date
______________________________________________ ______________________________________________
Applicant printed name Co-Applicant printed name
Mail completed application to:
Housing Kitsap
ATTN: Self-Help Intake
345th
Street, Suite 100
Bremerton, WA 98337
- OR -
Fax completed application to: (360) 535-6169
- OR -
Email completed application to: Marketing@HousingKitsap.org
For questions, please call:
Local: (360) 535-6139
TDD: (360) 535-6106
Toll Free: 1(800) 693-7070 x 6140
This is an Equal Opportunity Program.
Discrimination is prohibited by Federal Law.
Complaints of discrimination may be filed
With USDA, Office of Civil Rights
1400 Independence Ave., SW Washington, DC 20250-9410
Telephone: (866) 632-9992 TDD (202) 401-0216