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Personal Information Client Intake Form

Note: If you have an impairment, disability, language barrier, or otherwise require an alternative means of completing this form or accessing information about housing counseling, please talk to your housing counselor about arranging alternative accommodations.

Applicant Information

Name *

First

Middle

Last

Date of Birth *

Gender

Male
Female
Other

Last 4 of Social Security *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Do you live in a rural area?

Yes
No
Unsure

Number in household (include self) *

Main Phone *

Alternative Phone

Email *

Preferred Method of Contact

Phone
Email

Are you English Proficient? *

Yes
No
I have a translater

Marital Status *

Highest Level of Education *

Grade School
High School
College
Other

Race *

Asian
White
Black/African American
Native Hawaiian/Pacific Islander
American Indian/Alaskan Native
American Indian/Alaskan Native & White
Other
Decline to Provide

Ethnicity *

Hispanic
Non-Hispanic

Are you a Veteran? *

Are you Disabled? *

Referral Source *

Appointment Preference *

Virtual
In-Person
Phone

If other, please provide.

Secondary Applicant Information

Name (Applicant 2)

First

Last

Date of Birth (Applicant 2)

Gender (Applicant 2)

Male
Female
Other

Last 4 of Social Security (Applicant 2)

Main Phone (Applicant 2)

Alternative Phone (Applicant 2)

Email (Applicant 2)

Preferred Method of Contact (Applicant 2)

Phone
Email

Are you English Proficient? (Applicant 2)

Yes
No
I have a translater

Marital Status (Applicant 2)

Race (Applicant 2)

Asian
White
Black/African American
Native Hawaiian/Pacific Islander
American Indian/Alaskan Native
American Indian/Alaskan Native & White
Other
Decline to Provide

Ethnicity (Applicant 2)

Hispanic
Non-Hispanic

Are you a Veteran? (Applicant 2)

Are you Disabled? (Applicant 2)

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Employment Status / Income & Expenses

Please list current employment for all persons in your household who are employed. If you work more than one job, list them all. Choose the “Add” button to add additional employment. For budgetary purposes, it is very important to understand the difference between every other week and bi-monthly pay. If you are unsure, please consult with your counselor.

Employment

Employer Name *

(Ex. Target)

Employee Title *

(Ex. Sales Clerk)

Start Date *

(MM/YYYY)

Years in Profession *

Who's Job? *

Hours per week? *

Gross Income *

(before taxes)

Pay Schedule *

Additional Income

Does anyone in your house receive any of the following? Check a box for each.

Type

Who receives it?

How much?

How often?

Child Support

Child Support

Who receives it? (Child Support)

How Much? (Child Support)

How Often? (Child Support)

Alimony

Alimony

Who receives it? (Alimony)

How Much? (Alimony)

How Often? (Alimony)

Social Security

Social Security

Who receives it? (Social Security)

How Much? (Social Security)

How Often? (Social Security)

Unemployment

Unemployment

Who receives it? (Unemployment)

How Much? (Unemployment)

How Often? (Unemployment)

Worker's Compensation

Worker’s Compensation

Who receives it? (Worker's Compensation)

How Much? (Worker's Compensation)

How Often? (Worker's Compensation)

Veteran's Benefits

Veteran’s Benefits

Who receives it? (Veteran's Benefits)

How Much? (Veteran's Benefits)

How Often? (Veteran's Benefits)

Disability Benefits

Disability Benefits

Who receives it? (Disability Benefits)

How Much? (Disability Benefits)

How Often? (Disability Benefits)

Housing Assistance Voucher

Housing Assistance Voucher

Who receives it? (Housing Assistance Voucher)

How Much? (Housing Assistance Voucher)

How Often? (Housing Assistance Voucher)

Food Stamps or TANF

Food Stamps or TANF

Who receives it? (Food Stamps or TANF)

How Much? (Food Stamps or TANF)

How Often? (Food Stamps or TANF)

Other

Other

Who receives it? (Other)

How Much? (Other)

How Often? (Other)

Monthly Expenses

Please fill in your current monthly expenses. Leave the adjusted column blank for your discussion with the counselor.

Fixed Expenses

Expense

Current

Mortgage/Rent

Current (MORTGAGE/RENT)

ELECTRIC

Current (ELECTRIC)

gAS/OIL

Current (GAS/OIL)

WATER/SEWER

Current (WATER/SEWER)

PHONE BILL

Current (PHONE BILL)

TRASH PICKUP

Current (TRASH PICKUP)

INTERNET

Current (INTERNET)

CABLE TV/SUBSCRIPTIONS

Current (CABLE TV/SUBSCRIPTIONS)

AUTO INSURANCE

Current (AUTO INSURANCE)

LIFE INSURANCE

Current (LIFE INSURANCE)

MEDICAL INSURANCE

Current (MEDICAL INSURANCE)

RENTER’S INSURANCE

Current (RENTER'S INSURANCE)

CHILD CARE

Current (CHILD CARE)

CHILD SUPPORT/ALIMONY

Current (CHILD SUPPORT/ALIMONY)

HOA

Current (HOA)

TOTAL (A)

Current (TOTAL A)

Flexible Expenses

Expense

Current

SAVINGS

Current (SAVINGS)

GROCERIES

Current (GROCERIES)

EATING OUT

Current (EATING OUT)

ENTERTAINMENT/HOBBIES

Current (ENTERTAINMENT/HOBBIES)

BEAUTY/BARBER SHOP

Current (BEAUTY/BARBER SHOP)

hair supplies

Current (HAIR SUPPLIES)

MANICURE/PEDICURE

Current (MANICURE/PEDICURE)

LAUNDRY/DRY CLEANING

Current (LAUNDRY/DRY CLEANING)

CLEANING SUPPLIES

Current (CLEANING SUPPLIES)

CLOTHING

Current (CLOTHING)

gasoline

Current (GASOLINE)

public transit

Current (PUBLIC TRANSIT)

tuition

Current (TUITION)

school supplies

Current (SCHOOL SUPPLIES)

alcohol/cigarettes

Current (ALCOHOL/CIGARETTES)

church offerings

Current (CHURCH OFFERINGS)

auto maintenance

Current (AUTO MAINTENANCE)

house maintenance

Current (HOUSE MAINTENANCE)

pet expenses

Current (PET EXPENSES)

fitness

Current (FITNESS)

lottery/bingo

Current (LOTTERY/BINGO)

medical Co-Pays

Current (MEDICAL CO-PAYS)

medical prescriptions

Current (MEDICAL PRESCRIPTIONS)

other/misc

Current (OTHER/MISC)

tOTAL

Current (Total B)

Creditor Payments

Expense

Current

STUDENT LOAN

Current (STUDENT LOAN)

INSTALLMENT LOAN

Current (INSTALLMENT LOAN)

PAYDAY/TITLE LOAN

Current (PAYDAY/TITLE LOAN)

CREDIT CARD 1

Current (CC1)

CREDIT CARD 2

Current (CC2)

CREDIT CARD 3

Current (CC3)

CREDIT CARD 4

Current (CC4)

OTHER 1

Current (OTHER 1)

OTHER 2

Current (OTHER 2)

OTHER 3

Current (OTHER 3)

OTHER 4

Current (OTHER 4)

TOTAL

Current (Total C)

Assets

Any additional funds or savings you have.

Savings Account

Retirement Account

Other Accounts

Save and Resume Later

it? of "No"

Housing Status & Housing Goals

Current Housing Status: *

Renting/Leasing
Homeless
Boarder (renting room)
Homeowner with mortgage(s)
Homeowner (no mortgage)
Living with Family
Reverse Mortgage
Other

If Other

Housing Goals (check all that apply): *

Buy a home (pre-purchase counseling)
Transition from homelessness
Discuss a fair housing rights violation
Get credit & budget counseling
Obtain a reverse mortgage
Obtain rental counseling
Prevent foreclosure
Other

If Other

Rental and Mortgage Information

If you are currently renting, how long have you been renting?

Years

Months

Check all that apply:

I pay rent with no problem
I need assistance finding housing
I am facing eviction
I am interested in filing a fair housing claim

Specify reason(s)

If you own your property and have a mortgage, please answer the questions below:

Question

First Mortgage

Second Mortgage

Is this loan Current or Delinquent?

C/D 1

C/D 2

Mortgage servicer name?

Mortgage Servicer 1

Mortgage Servicer 2

Loan number

Loan Number 1

Loan Number 2

Loan Balance

Loan Balance 1

Loan Balance 2

Interest Rate

Interest Rate 1

Interest Rate 2

Mortgage Payment Amount

Mortgage Payment 1

Mortgage Payment 2

Fixed or Adjusting Interest rate?

F/A 1

F/A 2

Date you made your last payment?

Date 1

Date 2

Past due amount?

Past Due 1

Past Due 2

If you have previously applied for a loan modification or forebearance, please provide details on the outcome of the your previous foreclosure prevention efforts.

Explanation 1

Explanation 2

Reason for Default:

Divorce/Separation
Disability
Decrease in Income
Increase in Expenses
Medical Hardship
Other

If Other

Has your hardship ended?

When did it begin?

Do you have the ability or willingness to resume mortgage payments?

If "No" are you seeking an alternative outcome such as a deed-on-lieu of foreclosure or short sale? Explain.

Signature

Clear Signature

By signing electronically, I agree that my electronic signature is legally binding and that I consent to receive and sign documents electronically.

Date

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