English Counseling Form

Preferred Language *

English

Español

Program *

APPLICANT

Full Name *

Email *

Street *

Apt #

City *

State *

Zip Code *

Home Phone *

Cell *

Social Security # *

Birth Date *

Gender *

Male

Female

Other/Non-Conforming

First Time Home Buyer *

Yes

No

Handicapped *

Yes

No

Veteran *

Yes

No

Current Housing Arrangement *

Rent

Living with family member

Homeless

Rent *

Household Type *

Family Size *

Dependents *

Monthly Income *

Household Income *

Employer Name *

If not working enter n/a

Employer Phone Number *

If not working enter your phone number

Hourly Rate *

Yrs. On this Job *

Education Level (please check one) *

Ethnicity Hispanic *

Yes

No

CO APPLICANT

Full Name

Relationship to Applicant

Email

Street

Apt #

City

State

Zip Code

Home Phone

Cell

Social Security #

Birth Date *

Gender

Male

Female

Other/Non-Conforming

First Time Home Buyer

Yes

No

Handicapped

Yes

No

Veteran

Yes

No

Current Housing Arrangement

Rent

Living with family member

Homeless

Rent

Household Type

Family Size

Dependents

Monthly Income

Household Income

Employer Name

Employer Phone Number

Hourly Rate

Yrs. On this Job

Education Level (please check one)

Ethnicity Hispanic

Yes

No

REFERRED TO HOMEOWNERSHIP CENTER BY: (PLEASE CHECK ALL THAT APPLY)

Lender Name *

Realtor Name *

Referred by other *

AUTHORIZATION & CERTIFICATION

Request and Authorize NHS HomeOwnership Center to:

Pull my/our credit report to review my/our credit file for housing counseling in connection with my pursuit of a loan to purchase real property.

Authorization Type

Face to Face authorization

Over the phone

Date

Time

Date

Time

Client’s Certification:

I/We certify that the information included in this form is true and complete to the best of my/our knowledge and belief.

Applicant Signature *

Clear

Date

Text

Co-Applicant Signature

Clear

Date

AUTHORIZATION, DISCLOSURE, PRIVACY STATEMENT (3-in-1)

NHSGB COUNSELING SERVICES AUTHORIZATION

My personal information and counseling services

By signing this form, I agree to share my personal financial and other private information. Signing this form also allows lenders and Neighborhood Housing Services of Greater Berks, Inc. (NHSGB) to discuss my accounts, credit, and finances, and to share my nonpublic personal information, described in the Privacy Policy provided with this authorization.

I understand that funders provide grants to make the counseling services possible, and that NHSGB shares my information with these funders. These funders review NHSGB files, including my file, and may contact me to evaluate the counseling services that I receive.

I authorize my Counselor and NHSGB to negotiate for me. The counseling services are offered free of charge, and neither the Counselor, nor NHSGB, guarantees any result or outcome. I may be referred to other housing agencies for their services. I am not obligated to accept services or products from NHSGB, its partners, or any organization I am referred to.

I understand that my Counselor cannot offer me legal or other professional advice or representation. If I need legal or other professional services, I can ask my Counselor for information about referral services.

Counseling Services Checklist

Client must initial all items that are applicable

I have been verbally advised of the fee schedule, if any, prior to services being provided

Initials

I understand that the counselor will discuss my budget with me, and I will receive a copy of my Budget

Initials

I understand that the counselor will discuss my Action Plan with me, and I will receive a copy of my Action Plan

Initials

I understand the counselor will explain the next steps needed to reach my financial goal to my satisfaction

Initials

Homebuyer Counseling

Initials

Homebuyer Education

Initials

Homeowner Counseling for Repair Program

Initials

Delinquency and Default Education

Initials

I want to buy a home in the next six (6) months

Initials

I want to buy a home, but not in the next six (6) months

Initials

Other programs, services, or products:
For all Pre-Purchase, Pre-Closing, Homebuyer Counseling & Education Clients only:

Initials

I have received the HUD forms:
“Ten Important Questions to Ask Your Home Inspector” & “For Your Protection: Get a Home Inspection”

Initials

NHSGB Information

Counselor Name

Phone

NHSGB

Email

CounselorMax Case ID

Fax

RX Client Number

AUTHORIZATION, DISCLOSURE, PRIVACY STATEMENT (3-in-1)

PRIVACY POLICY

This NHSGB respects the privacy of the people that come to us for assistance. We understand that the matters you discuss with us are very personal. All spoken and written information shared with us will be managed with our legal and ethical obligations to you taken into consideration. We will not sell your personal information and we only share it to provide you with counseling services.

Your “nonpublic personal information” (including total debt information, income, living expenses, and personal information concerning your financial circumstances) will be shared with creditors, funders, and others only after you sign the Counseling Services Authorization. We may also collect, use, and share anonymous aggregated case file information to evaluate our services, to gather valuable research information, and to design future programs.

Types of Information That We Gather About You:

Spoken or written information on applications and other documents, such as your name, address, social security number, assets, and income;
Information about your transactions with us, your creditors, or others, such as your account balance, payment history, parties to transactions and credit card usage; and
Information we receive from a credit reporting agency, such as your credit history.

You May Opt-Out If You Do Not Want Us to Share Your Information:

You may "opt-out" to prevent the disclosure of your nonpublic personal information to third parties (such as your creditors).
If you opt-out we cannot share your nonpublic information and we cannot answer questions from your creditors. We need to share your information to provide you with most services.
You may opt-out at any time by calling NHSGB at the phone number listed on the Counseling Services Authorization provided with this Privacy Policy.

How We Use Your Information:

If you do not opt-out we may share information that we collect about you with your creditors or others if we think it would be helpful to you, would help us counsel you, or when required by funders that make our services possible. We may share information about you to anyone as permitted or as required by law (e.g., if a Court requires us to provide it with documents).

Within our organization, we restrict access to your information to those employees who need to know that information to provide services to you. We maintain physical, electronic, and procedural safeguards to protect your information as required by federal and state law.

Client Authorization

By signing below, I authorize my employers, lenders, creditors, servicers, and others to share personal and financial information with my Counselor and NHSGB. I authorize my Counselor and NHSGB to collect information about my accounts and to share this information with others, including funders, as needed to provide counseling services, to seek assistance from programs, or for related products and services. I authorize funders to contact me to evaluate programs that I participate in.

CLIENT NAME(S):

CLIENT SIGNATURE(S):

DATE:

CLIENT NAME *

CLIENT SIGNATURE *

Clear

DATE

CLIENT NAME

CLIENT SIGNATURE

Clear

DATE

APPLICANT

CO APPLICANT

REFERRED TO HOMEOWNERSHIP CENTER BY: (PLEASE CHECK ALL THAT APPLY)

AUTHORIZATION & CERTIFICATION

Request and Authorize NHS HomeOwnership Center to:

Client’s Certification:

AUTHORIZATION, DISCLOSURE, PRIVACY STATEMENT (3-in-1)

NHSGB COUNSELING SERVICES AUTHORIZATION

My personal information and counseling services

Counseling Services Checklist

NHSGB Information

AUTHORIZATION, DISCLOSURE, PRIVACY STATEMENT (3-in-1)

PRIVACY POLICY

Types of Information That We Gather About You:

You May Opt-Out If You Do Not Want Us to Share Your Information:

How We Use Your Information:

Client Authorization

CLIENT NAME(S):

CLIENT SIGNATURE(S):

DATE:

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