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1704 Bellefontaine St., Indianapolis, IN 46202

Income Digital Form

Thank you for your interest in purchasing a home! In order to start the process, please review the information below and completely fill out the form with the necessary information.

CONSENT: I authorize and direct any federal, state or local agency, organization, business or individual to release information to representatives of Intend Indiana, which may be necessary for me to qualify to receive federal assistance. I understand and agree that this authorization or the information obtained with its use may be given to and used to administer and enforce program rules and policies in compliance with HUD, IHCDA, CDBG and HOME Program or other governmental housing program guidelines. I also consent for the manager to release information from my file to the Indianapolis Housing Partnership (INHP) for pre-screening purposes.

INFORMATION COVERED: I understand that previous or current information regarding myself or my household may be needed. Verification and inquiries that may be requested include but are not limited to:

  • Identity and marital status
  • Property ownership status
  • Employment income, assets, pension or benefits
  • Credit activity

GROUPS OR INDIVIDUALS THAT MAY BE ASKED: The groups of individuals that may be asked to release the above information (depending on the program requirements) include but are not limited to:

  • Additional lien holders
  • Welfare or supportive service agencies
  • Social Security Administration
  • State Employment Bureaus and Services
  • Banks and other financial institutions
  • Children Services
  • Past and present employers
  • Courts and post offices
  • Schools and Colleges
  • Child Support/alimony providers
  • Retirement systems
  • Utility companies

CONDITIONS: I agree that a photocopy or facsimile of this authorization may be used for the purposes stated above. The original of this authorization is on file in the Intend Indiana office and will stay in effect for one year and six months from the date signed.

Please read over the information and requirements necessary to complete the Homeowner Contact and Information Sheet below.


1 Persons 2 Persons 3 Persons 4 Persons 5 Persons 6 Persons 7 Persons 8 Persons
80% $54,150 $61,900 $69,650 $77,350 $83,550 $89,750 $95,950 $102,150



Please attach the following:

  • Provide the following income verification documents for ALL household members:
    • Most recent award letters (Social Security, Supplemental Security Income (SSI))
    • 3 consecutive months of recent paystubs
    • Current documentation for all other forms of income, including but not limited to: unemployment benefits, military income, public assistance (not including food stamps), child support payments (past 12 months), alimony, retirement funds, pensions, real estate property income, etc.
    • Most recent bank statements (Current Savings account and 6 months average for Checking account)
    • EACH household member 18 and over must fill out and sign the attached “Income Certification Questionnaire” and “Authorization for Release of Information Form
  • Copy of Identification (current State ID or Drivers License)
  • Copy of Social Security Cards (for all household members)

Disclosure/Privacy Statement

Services will be provided without discrimination because of age, race, color, religion, sexual orientation, gender identity, handicap, national origin or ancestry. The agency is requesting information necessary to comply with the requirements of the housing program. I understand that the information on this form will be kept confidential but may be shared with other agencies to which I may be referred for services. I understand that I may be requested to verify these statements, and give my consent to this agency to make necessary contacts to verify any statements. I understand that additional information may be required based upon my answers.


(*NOTE: A separate questionnaire must be completed by each adult member of the household)

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