IDA/FOA Application/Intake Form
Personal Information
Name: ____________________________________ Social Sec. No. _____________________
Street: ____________________________________________ Apt #: __________________
City: ______________________________ State: ____ Zip Code: ________________
Home Phone: (____)_________ Work Phone: (____)_________ Pager: (____)___________
Alternative Contact Number: (____) _________ Email:______________________________
Are you a United States citizen? ____________________________________________________
Who referred you to the IDA/FOA Initiative?__________________________________________
Do you have any special needs our staff should know about? ______________________________
Emergency Contact Information
Please list a relative or friend who would definitely know how to contact you, even if you move:
Name: ____________________________________________ Phone: (____)___________
Street: _______________________________________________ Apt #:_____________
City: __________________________________ State:_____ Zip Code: __________
Household Information
How many adults (18yrs and older) currently live in your household: ____________
How many children (under 18yrs) currently live in your household: _____________
Your marital status: o Single (never married) o Married o Separated
o Divorced o Widowed
What is the primary language spoken in your household? ______________________________
If it is not English, is English also spoken? __________________________________________
Employment Information
Primary Employment Status (check one):
o Employed more than full-time (40 + hours, overtime or more than one job, for yourself or others)
o Employed full-time (40 hours, for yourself or others)
o Employed part-time (20 hours, for yourself or others) o Currently seeking employment
o Working and in school or job training o Homemaker, not seeking employment
o Laid off, waiting for call back o Disabled, not seeking employment
o Currently in school or job training o Retired, not seeking employment
Employer: _____________________________________________ Phone: (____)__________
Street: _____________________________________________________________________
City: ____________________________________ State: ____ Zip Code: __________
Income Information
Please note: The income figures should reflect all the household income. If there is more than
one wage earner per household, documentation must be provided for each one. Please complete
ONE of the three answers below.
Please provide verification of all sources of income (i.e., copies of your tax forms, pay stubs, copies
of assistance payments, etc.)
1.Your household’s adjusted gross income as shown on IRS Form 1040EZ or Form 1040A, or Form 1040.
Tax Year: Amount
Tax Year: Amount
2. Did your household file for a Federal Earned Income Tax Credit this past year?
Will you be eligible to file for the EITC this coming tax season?
3. Household income as calculated in the Adjusted Gross Income worksheet $
Credit Information
Please provide the most recent credit score information available. Score: Date:
Personal Statement
Please explain why you are interested in participating in the IDA program. Be sure to describe the
asset you would be interested in purchasing with your IDA savings.
Certification
My signature below certifies that all information provided on this application, and referenced
within this application is accurate and complete to the best of my knowledge. I certify that I
do not have another IDA/FOA open with any other organization at this time.
Signature: __________________________________________ Date: ____________
Translator: _________________________________________ Date: ___________
Applicants under age 18 must have the consent of a parent or guardian:
My signature below certifies that I am a parent or guardian of _____________ and that I consent to
his or her participation in the IDA Program.
Signature: __________________________________________ Date: ____________
Relationship to Participant: ______________________________________________________
For Office Use Only
Application Reviewed and Approved by: ____________________________ Date: ___________
Statistical Information
Please complete the following statistical information, which will assist in our data collection
requirements of our funder. This information will not impact your application to open an IDA.
Collection of this information is voluntary. We ask for your cooperation and assistance.
Gender: o Female o Male Age: ________ Date of Birth:____ / ____ / ____
Ethnicity: o African American o Caucasian
o Latino or Hispanic* o Asian, Pacific Islander
o Native American o Other (please specify: _______________________)
this data-collection procedure. Statistical information does not determine eligibility to hold an IDA)
US Census definitions: Latino = family origins of Latin American descent.
Hispanic = family origins of Spanish descent
Note: If your family origins are from both, please write “mixed: Latino & Hispanic”
in the “Other” space.
Place of Residence:
o Urban or suburban (population of 50,000 or more -- only within the city boundaries of Albuquerque, Santa Fe, Rio Rancho, Farmington, or Las Cruces
o Rural area (population between 2,500 and 50,000)
o Remote area (population of less than 2,500)
Highest Level of Education Completed:
o Grade K through 5 o Grade 6 through 8
o Grade 9 through 12 o High School Diplomas or GED
o Attended college o Graduated junior college (2 year)
o Graduated college (4 year) o Attended graduate school
Public Assistance – Current – Do you currently receive:
o TANF o SSI
o Food Stamps o Public Housing Assistance
oOther: What type?
Public Assistance – Past – Did you receive assistance in the past 12 months?
o TANF o SSI
o Food Stamps o Public Housing Assistance
o Other: o What type?
Once you have completed this application, send to:
Open Hands Attn: Jacquelyn Poplawsky
2976 Rodeo Park Dr. East Santa Fe, NM 87505-6351