Caribbean Disaster Mitigation Project
Implemented by the Organization of American States
Unit of Sustainable Development and Environment
for the USAID Office of Foreign Disaster Assistance and the Caribbean Regional Program

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Hurricane Resistant Home Improvement Program

Appendix B: Loan Application Form

All information given in this form will be held in the strictest confidence.

NAME: ________________________________

APPLICANT NO: _____________________________________

ADDRESS: __________________________________________

TEL NO. (H) __________________ (W) ___________________

SEX: M / F

AGE: _____________________

MARITAL STATUS: M / S / D / P

CONTACT ADDRESS: _________________________________

NO. OF DEPENDANTS: ________________________________

EDUCATIONAL BACKGROUND: ________________________

MAIN EMPLOYMENT: _________________________________

INCOME (P/M): _______________________________________

PLACE OF EMPLOYMENT: _____________________________

OTHER EMPLOYMENT: ________________________________

INCOME (P/M): _______________________________________

STATEMENT OF AFFAIRS

Assets Liabilities
Bank Accounts:

 

 

Bank Loans:

 

 

Land/Building:

 

 

Other Loans:

 

 

Vehicle:

 

 
Other:

 

Other:

 

Total Assets:

 

Total Liabilities:

 

Have you applied to ___________ before? Yes / No / Result: ___________________

Date of previous application _________________________

If rejected, reason ______________________________________________________

How did you find out about this loan program: ______________________________________________

Location: N / S / E / W / NE / SE / NW / SW

Area: Rural / Urban

Status of ownership of

(1)Building ______________________________

(2 ) Land _______________________________

If lease hold for any of the above, then a copy of the lease agreement must be submitted along with written permission from the Landlord to carry out the stated repairs.

Loan Amount requested: $_____________________

Purpose of Loan Request Details
Purchase of material:  
Payment of labour:  
Transportation:  
Other: ________________________  
Total Request:  

 

Initial Funding for construction of building __________________
Other Sources of Funding __________________
Amounts outstanding from ( 1 ) and ( 2 ) above $ _________________

Is Certificate of Title to Property available? Yes / No

What is the value of the property: $ ____________________________

Note: All applications must be accompanied by Bill of Quantities certified by an estimator recognized by __________________ as having the authority to do so.

Security Offered Value
   
   
   
   
Total value of securities  

Method of Repayment:

( 1 ) Salary Reduction ( Self )

( 2 ) Salary Deduction Guarantor

( 3 ) Authorization on Crop Sales

( 4 ) Other Sales

( 5 ) Over the Counter

I hereby certify that all the information given in this document is true and correct and that I have not held back any information which would negatively effect the decision to make the loan.

I further agree that as a condition of approval of the loan, that loan agency officers or anyone authorized by the loan agency Director will be allowed to inspect my premises at any reasonable time, during the renovation/operation, to obtain relevant information re the use of loan funds and compliance with the loan agreement.

 

Signed this ____ day of _____________, 20__

 

_________________________________________ _________________________________________
SIGNATURE OF APPLICANT SIGNATURE OF OFFICER

 

CDMP home page: http://www.oas.org/en/cdmp/ Project Contacts

Page Last Updated: 20 April 2001