English FASTRAC Intake Form

STUDENT/APPLICANT

Name *

First

Middle

Last *

Last

Street *

Apt#

City *

State *

Zip Code *

Social Security # *

Home Phone

Work

Cell

Birth Date *

Gender *

Male

Female

Over 62

Yes

Email

Ethnicity: Hispanic *

Yes

No

Chose Not to Respond

Foreign Born *

Yes

No

Chose Not to Respond

Household Type *

Single

Two or More Unrelated Adults

Female-Headed Single Parent Household

Male-Headed Single Parent Household

Married with Dependents

Married without Dependents

Handicapped *

Yes

No

Veteran *

Yes

No

Current Housing Arrangement *

Rent

Homeless

Living with family member and not paying rent

First Time Home Buyer *

Yes

No

Household Size That Will Live in Home *

How Many Are Dependents? *

Are There Non-dependents Who Will Live in The Home? *

Yes

No

If yes, list below:

Relationship

Age

Relationship

Age

Applicant Gross Monthly Income * $

Household Gross Monthly Income * $

Education Level *

Referred to HomeOwnership Center by: (please check all that apply) *

STUDENT/APPLICANT – CO APPLICANT

Name

First

Middle

Last

Social Security #

Address, if Different:

Street

Apt#

City

State

Zip Code

Home Phone

Work

Cell

Birth Date

Gender

Male

Female

Over 62

Yes

Email

Relationship to Applicant

Gross Monthly Income $

First Time Home Buyer

Yes

No

Handicapped

Yes

No

Ethnicity: Hispanic

Yes

No

Chose Not to Respond

Foreign Born

Yes

No

Chose Not to Respond

AUTHORIZATION & CERTIFICATION

Student’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.

I authorize Release of Information for NHS HomeOwnership Center to:

(a) Pull my/ our credit report to review my/ our credit counseling in connection with my pursuit of a loan to purchase real property;

(b) Obtain a copy of the closing disclosure, appraisal, real estate Note(s), Credit Score, and income Documentation when I purchase a home, from the lender who made me/us a loan and/or the title company that closed the loan.

Student’s Signature *

Clear

Date *

Student’s Signature

Clear

Date

STUDENT/APPLICANT

If yes, list below:

STUDENT/APPLICANT – CO APPLICANT

AUTHORIZATION & CERTIFICATION

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