Individual Development Account Online Application ⋆ Mercy Corps Northwest

This application will take approximately 60 minutes to complete. You will have the option to save and continue. Please, DO NOT submit an incomplete application as it will not be considered. If you don't have the required documentation, save and finish it when you can upload the required documents. The "Save" button is located at the bottom of the page

For those who are recipients of either LIEAP, Public Housing, Section 8, SNAP, TANF, Low Income Tax Credit properties, or WIC: If you can provide documentation of participation certified within the last 12 months on letterhead or some other official document, then you do not have to submit verification of income, or bank statements. You only need to include (in addition to the certification letter):

Copy of Oregon ID
Optional: An explanation of any special circumstances to be considered

For those who are not receiving any of those forms of public assistance, your application must include:

1) Copy of Oregon ID (or utility bill/lease agreement)
2) Last year’s BUSINESS tax return (Personal tax return is not required)
3) 1 months bank statement from each bank account in the household (personal and business):
3) Proof of income eligibility:
One or more of the following forms of proof of earned income for last 2 months:
– pay stubs showing gross income
– letter of employment–if you do not receive pay stubs or are working “under the table,” please provide a letter that includes the following information: your name, hours worked over the last two months/pay rate, and signature of employer.
– A 2-month profit and loss statement if you have income from self-employment. A profit and loss sheet should show all of your business expenses, which are then subtracted from your gross sales to show your profit. It doesn’t have to be fancy, but it should allow us to understand how much you are bringing home from your self-employment.
4) An explanation of any special circumstances to be considered (no more than half a page, please)
In some cases we reserve the right to ask for detailed personal and business bank statements for last 2 months for all household members (must have name and account number on the top).

We strongly recommend compiling this information prior to starting the application.
A PDF of this application is also available.

Basic Information

Educational Requirement: In the last 12 months have you completed the Business Foundations I or II at MCNW, the 4-week Business Plan workshop, the Business class through the Livelihood NW, the MCNW Master Your Credit class, or an equivalent class (which you have had approved by the IDA staff)? If no, please do not apply at this time.*

Please describe the pre-qualifying course taken and give the month/year of attendance. If you completed the course with MCNW just write down the name of the class.

If you have not completed a class, please do not continue with this application. Consider applying during the next application period (Fall 2020).

First Name*

Middle Name

Last Name*

Home address*

Street Address City State ZIP Code

In what COUNTY is your home address?*

Primary Phone Number*

Mobile / Alternate Phone Number

Email Address*

Alternate Email Address

Personal Information

At Mercy Corps NW we encourage individuals of all backgrounds to apply for our programs but particularly welcome people from traditionally underserved/undercapitalized populations as well as those who are transitioning from incarceration and the homeless/housing insecure.

Gender*

Birth Date*

Race or ethnicity (select all that apply)*

Black / African American
Asian or Pacific Islander
White
American Indian or Alaska Native
Multicultural
Decline to ID

Do you identify as another race or ethnicity? Please specify*

Do you identify as Hispanic?*

Yes
No

What is your native language?*

What is your COUNTRY of origin (in what country were you born)?*

Marital Status*

Family Type*

Housing Type*

Please choose the option that best describes your household's living situation. NOTE: If you are a youth living with family members, choose ‘Youth Living with Family Members’ regardless of whether your family rents or owns a home. Couch surfing, camping, and living in emergency shelters constitute homelessness.

Veteran?*

Veteran can refer to any applicant who identifies as a veteran from any country.

Yes
No
Decline to ID

Highest level of education completed?*

Veteran can refer to any applicant who identifies as a veteran from any country.

Did you complete your education outside the United States? If so, where?

Do you identify as having a disability?*

Yes
No
Decline to ID

Were you in foster care between ages 15-21?*

Yes
No
Decline to ID

Have you ever been incarcerated?

All individuals are eligible to apply, regardless of their level of involvement with the justice system.

Household Information

Household Income

Definition of a household: all individuals who share use of a dwelling unit as primary quarters for living and eating, separate from other individuals. If you can answer “yes” to all of the following questions about the people who live with you, then you are all considered a household for IDA eligibility purposes: 1) Do you share a dwelling unit (a home, an apartment, or other living space)? 2) Does everyone consider the dwelling unit their primary dwelling place? (Do they stay at this location for the majority of their time?) 3) Do you identify as a household?) Roomates, who split expenses and eat separately from each other, typically don't consider themselves as part of a household.

Members of Household*

Please list the name, date of birth, and relationship to you (wife, husband, son, daughter, etc.) of *all* members of your household (including yourself). A household is defined as people who share a space and food. Roommates do not count. Also, please estimate the amount of money they earn each month from all sources (self-employment, wages, SSI, cash assistance, etc.).

Name	Date of Birth	Relationship	Income per month

Your current employment Status*

Did you or someone in your household file taxes last year?*

Yes
No
Unsure

If you filed a tax return last year, what was your adjusted gross income? (If you filed "Married Filing Separately" give the total adjusted gross income for BOTH you and your spouse).*

Please attach your last year's BUSINESS tax return (if you were in business). Personal tax returns are not required.

Drop files here or

Sources of Income for All Household Members*

Please list all sources of income for your household. Include: gross salary or wages, investment income, alimony, TANF or other forms of cash general assistance, SSI, SSD, Unemployment, Retirement income, Dependent benefits and all other sources of income. Click the + sign to add a new line.

Name of Household Member	Source of Income	Frequency Received (Weekly/Bi-Monthly/Monthly). If it is occassional income, specify how often.	Amount Received (per pay period)

Attach proof of earned income here*

Were you certified to receive one of the following in the last 12 months: LIEAP, Low-Income Tax Credit Properties, Public housing, Section 8, SNAP, TANF, and/or WIC? If so, you do not need to provide proof of household income here. Rather, if you prefer, you can provide letterhead or some other official document from the organization showing your proof of eligibility or enrollment within the last 12 months. All others: please provide proof of earned income for the past TWO months for all members of the household. (If you receive weekly paychecks, provide copies of the last 8 paystubs; If you are paid monthly, you will provide two paystubs.) You are NOT required to provide documentation for any income that doesn't come from work, i.e. cash assistance, child support/alimony, investment income, retirement income, etc. Attach as many files as you need. NOTE: There MUST be some source of income in the household, equal to the amount you will be saving for the IDA--$25-$100. If you are paid informally ("under the table") please attach a statement written and signed by yourself, stating how much you have earned in the last 60 days. Income earned from your business will be entered in the next section. NOTE: This is required. Your application will not be considered unless this information is included. If you do not have this information ready, please save the application and continue it when you are ready to upload it.

Drop files here or

Are you self-employed?*

Yes
No

Are you self-employed?*

Full-time (35+hrs/week)
Part-time or seasonal
Decline to ID
Other

Self-Employment (Business) Gross Sales*

If you work for cash or own your own business, how much did you gross in sales in the last TWO months? NOTE: If you are self-employed, this is required. Your application will not be considered unless this information is included. If you do not have this information ready, please save the application and continue it when you are ready to upload it.

Business Expenses (Past Two Months)*

What expenses did you have in running your business over the last two months? This includes (but isn't limited to): cost of goods sold, payroll for employees (not for yourself or members of your household) overhead (rent, utilities, supplies, etc.), transportation, shipping costs, credit card fees, etc. Remember to keep your personal expenses separate from your business ones. Please list each expense and the frequency it is paid. Please don't itemize each transaction, just bundle expenses into categories, such as "office supplies." If it was an unusual expense (such as a yearly licensing fee), please make note of that under the "note" section. NOTE: This is required. Your application will not be considered unless this information is included. If you do not have this information ready, please save the application and continue it when you are ready to upload it.

Type of expense	Amount paid	Note

Net Business Income*

Subtract your expenses from your sales. This is your net income for the past two months. Please enter the result below.

Upload Profit and Loss sheet here.

A profit and loss sheet should show all of your business expenses, which are then substracted from your gross sales to show your profit. It doesn't have to be fancy, but it should allow us to understand how much you are bringing home from your self-employment.

At what stage is your business?*

Note, if you are still in the process of developing your business idea please select 'Conceptual'.

Conceptual (have an idea, did some research)
Startup (in business less than 1 year)
In business for a year or more

Do you receive Section 8 housing?

Yes
No

Do you receive SNAP (Food stamps)?*

Yes
No

Do you receive TANF?*

Yes
No

Have you ever been registered on the ChexSystems?*

Yes
No

Net Worth Calculation

Assets

Note: your net assets must total less than $20,000. We ask about but do not count your first house, car, or $60,000 in retirement savings.

Are you a vehicle owner?*

Yes
No

Vehicle 1 Value

Vehicle 2 Value

Vehicle 3 Value

Are you a homeowner?*

Yes
No

Home/Condo 1 Value

Home/Condo 2 Value

Do you have a checking account?*

Yes
No

Amount in checking account*

Notes: If the checking account balance is negative, please include it in the liabilities section under ‘Other Debts’.

Please upload 1 month's bank statement for each checking account in the household. The statement must be detailed and have your name and account number.

Do you have a savings account?*

Yes
No

Amount in savings account

Please upload 1 month's bank statement for each savings account in the household. The statement must be detailed and have your name and account number.

Drop files here or

Amount in children's savings account / CDs

Do you have a business bank account?*

Yes
No

Amount in business bank account*

Please enter a number greater than or equal to 0.

Please upload 1 month's bank statement for each business bank account in the household.

NOTE: This is required. Your application will not be considered unless this information is included. If you do not have this information ready, please save the application and continue it when you are ready to upload it.

Drop files here or

Does your business have any assets or inventory?*

Yes
No

Value of business assets/inventory*

We are only interested in items valued over $1000 per item. Please enter zero if you do not have business assets or inventory whose individual value exceeds that amount.

Please enter a number greater than or equal to 0.

Do you have a retirement account (401K, IRA, etc)?*

Yes
No

Amount in retirement account(s) over $60,000. (Example: if you have $75k in the account, please put $15k as your answer. If you have $50k in the account, put "0."*

Please enter zero if you do not have a retirement account.

Please enter a number greater than or equal to 0.

Do you own any stocks or hold any bonds? (non-retirement)*

Yes
No

Value of stocks and bonds*

Please enter zero if you do not hold stocks and bonds.

Please enter a number greater than or equal to 0.

Cash on hand*

Value of any other investments

Value of any other assets

TOTAL ASSETS*

IDA Eligible Total Assets

Debts or Liabilities

Do you have a vehicle loan?*

Yes
No

Vehicle 1 Loan Balance

Vehicle 2 Loan Balance

Do you have a mortgage?*

Yes
No

Home/Condo 1 Loan Balance

Home/Condo 2 Loan Balance

Do you have any unpaid income or property taxes?*

Yes
No

Amount you owe in unpaid taxes*

Please enter zero if you do not owe unpaid taxes.

Please enter a number greater than or equal to 0.

Do you have any past due child support payments?*

Yes
No

Amount you owe in past due child support*

Please enter zero if you do not owe past due child support.

Please enter a number greater than or equal to 0.

Do you have any credit card bills?*

Yes
No

Amount of credit card balance(s)*

Please enter zero if you do not have a credit card balance.

Please enter a number greater than or equal to 0.

Store credit debt*

Please enter zero if you do not have a store credit debt.

Please enter a number greater than or equal to 0.

Personal line of credit debt*

Please enter zero if you do not have a line of credit.

Do you have any outstanding medical bills?*

Yes
No

Outstanding balance of medical bills*

Please enter zero if you have no outstanding medical bills.

Do you owe money to friends or family members?*

Yes
No

Amount you owe to friends and family*

Please enter zero if you do not owe money to friends and family.

Please enter a number greater than or equal to 0.

Do you have any outstanding student loans?*

Yes
No

Balance of outstanding student loans*

Please enter zero if you have no outstanding student loans.

Please enter a number greater than or equal to 0.

Do you have any business debts?*

Yes
No

Balance of outstanding business debts*

Please enter zero if you have no outstanding business debts.

Please enter a number greater than or equal to 0.

Do you have any other debts?*

Yes
No

Balance of all other debts

TOTAL DEBTS*

IDA eligible debt*

FULL NET WORTH*

IDA ELIGIBLE NET WORTH*

NOTE: If your total IDA eligible net worth is over $20,000, then you do not qualify for the IDA program at this time.

Individual Development Account Online Application

For those who are not receiving any of those forms of public assistance, your application must include:

Basic Information

Personal Information

Household Information

Household Income

Net Worth Calculation

Assets

Debts or Liabilities

IDA Purposes

Business Plan

Proposed Purchase List

Required Documents

Mercy Corps Northwest is part of Mercy Corps Global.

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