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K. DEMOGRAPHIC AND SPECIAL NEEDS INFORMATION: The Texas Department of Housing and Community Affairs (TDHCA)
requests this information in order to comply with HUD’s required reporting requirements. Although TDHCA would appreciate
receiving this information, you may choose not to furnish it. You may not be discriminated against on the basis of this information,
or on whether or not you choose to furnish it. If you do not wish to furnish this information, please initial below.
Applicant I do not wish to furnish information regarding my ethnicity, race, gender, age, and/or household composition.
Initials
Ethnicity Codes:
A – Hispanic: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Terms such as “Latino” or
“Spanish Origin” apply to this category.
B – Not Hispanic
Race Codes: F – American Indian/Alaska Native/White
A – White G – Asian/White
B – Black‐African American H – Black/African American/White
C – Asian I – American Indian/Alaska Native/Black‐African American
D – American Indian/Alaska Native J – Other Multi‐Racial
E – Native Hawaiian/Other Pacific Islander
Special Needs Codes: E – Colonia Resident J – Disaster Victim
A – Elderly F – VAWA/Victim of Domestic Violence K – Veteran
B – Person with Disabilities* G – Homeless L – Wounded Warrior
C – Person with HIV/AIDS H – Migrant Farm Worker M – Money Follows the Person
D – Person with Alcohol and/or Drug Addiction I – Public Housing Resident
*Disability Definition: A physical or mental impairment which substantially limits one or more major life activities; a record of such an impairment; or being
regarded as having such an Impairment. Does not include current, illegal use of or addiction to a controlled substance.
Ethnicity Code Race Code Special Needs Code(s)
1 (Head)
2
3
4
5
6
7
L. RELEASE AND SIGNATURES
Each of the undersigned Applicants for HOME Program assistance hereby certify that all of the information provided in the above
Application is true and correct, and do hereby authorize the release and/or verification of mortgage loan, employment, asset,
liability, and income information. All household members age 18 or older must sign Application.
_____________________________________ _______________________________________ _________________________
Applicant’s Printed Name Signature Date
_____________________________________ _______________________________________ _________________________
Co‐Applicant’s Printed Name Signature Date
_____________________________________ _______________________________________ _________________________
Adult Household Member Printed Name Signature Date
_____________________________________ _______________________________________ _________________________
Adult Household Member Printed Name Signature Date
Warning: Title 18, Section 1001 of the U.S. Code makes it a criminal offense to make willful false statements or
Misrepresentations to any Department or Agency in the United States as to any matter within its jurisdiction.
DO NOT MAIL THIS TO THE ADDRESS BELOW – SEE BACK FOR ADDRESSES
Reasonable accommodations will be made for persons with disabilities and language assistance will be made available for
persons with limited English proficiency.
TEXAS DEPARTMENT OF HOUSING AND COMMUNITY AFFAIRS
Street Address: 221 East 11th Street, Austin, TX 78701 Mailing Address: PO Box 13941, Austin, TX 78711
Main Number: 512-475-3800 Toll Free: 1-800-525-0657 Email: info@tdhca.state.tx.us Web: www.tdhca.state.tx.us
TDHCA HOME Investment Partnerships Program March 2015
HOME Program Intake Application Page 5 
