Intake Form English

Form

Program

CREDIT COUNSELING

HOMEBUYER CLASS

CLOSING COST

LOAN ASSISTANCE

MY LIFE - REPAIR PROGRAM

APPLICANT

Full Name *

Email *

Street *

City *

State *

Zip Code *

Birth Date *

Phone # *

Social Security # *

Citizenship Status

Citizen

Permanent Resident

Non-Permanent Resident

Gender *

Male

Female

Other/Non-Conforming

First Time Home Buyer *

Yes

No

Handicapped *

Yes

No

Veteran *

Yes

No

Household Type *

Unmarried

Married

Separated

Family Size *

Dependents *

Monthly Income *

Household Income *

Employer Name *

If not working enter n/a

Hourly Rate *

Start Date *

Education Level (please check one) *

Below High School

High School or Equivalent

Other

Ethnicity Hispanic *

Yes

No

Race *

American Indian or Alaskan Native

Asian

White

Black or African American

Black or African American & White

Native Hawaiian or Other Pacific Islander

Chose Not to Respond

Other

Enter your race

CO APPLICANT

Full Name

Relationship to Applicant

Email

Street

City

State

Zip Code

Birth Date

Phone #

Social Security #

Citizenship Status

Citizen

Permanent Resident

Non-Permanent Resident

Gender

Male

Female

Other/Non-Conforming

First Time Home Buyer

Yes

No

Handicapped

Yes

No

Veteran

Yes

No

Household Type

Unmarried

Married

Separated

Family Size

Dependents

Monthly Income

Household Income

Employer Name

Hourly Rate

Start Date

Education Level (please check one)

Below High School

High School or Equivalent

Other

Ethnicity Hispanic

Yes

No

Race

American Indian or Alaskan Native

Asian

White

Black or African American

Black or African American & White

Native Hawaiian or Other Pacific Islander

Chose Not to Respond

Other

Enter your race

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

Are you currently working with a lender/bank

Yes

No

Name of Bank

AUTHORIZATION & CERTIFICATION

I Request and Authorize NHS of Greater Berks 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.

Client’s Certification:

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

Applicant Signature *

Clear

Date *

Co-Applicant Signature

Clear

Date

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

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 the Counseling Agency 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 the Counseling Agency shares my information with these funders. These funders review Counseling Agency files, including my file, and may contact me to evaluate the counseling services that I receive.

I authorize my Counselor and the Counseling Agency to negotiate for me. The counseling services are offered free of charge, and neither the Counselor, nor the Counseling Agency, 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 the Counseling Agency, 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 have discussed Home Buyer Options and related Pre-Purchase topics and I have received the HUD forms: “Ten Important Questions to Ask Your Home Inspector” & “For Your Protection: Get a Home Inspection”

Initials

I have received and reviewed a copy of the Fair Housing Pamphlet

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

Initials

Homeowner Education

Initials

Delinquency and Default Counseling

Initials

Delinquency and Default Education

Initials

Reverse Mortgage Counseling

Initials

Fair Housing Education

Initials

Tenant Counseling

Initials

Homelessness and Displacement Counseling

Initials

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

Initials

Post-Purchase Counseling

Initials

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

Initials

Credit & Budget Counseling

Initials

Other programs, services, or products:

Initials

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

PRIVACY POLICY

This Counseling Agency 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 the Counseling Agency at the phone number listed on the Counseling
Services Authorization provided with this Privacy Policy.

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 the Counseling Agency 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 the Counseling Agency. I authorize my Counselor and the Counseling Agency
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):

Applicant Signature *

Clear

Date

Client Name(S):

Applicant Signature

Clear

Date

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

COUNSELING AGENCY DISCLOSURES

Please Initial

For Client:

I understand I am not obligated to receive, purchase, or use services or products from the Counseling Agency, its partners, or any organization I am referred to by the Counseling Agency.

Initials

The Counseling Agency has described in detail the different types of services provided and any exclusive, financial or other relationship between the Counseling Agency and any other industry partners that may be relevant to my services, including the relationship between the Counseling Agency and funders.

Initials

I have been offered information on alternative services, programs, and products.

Initials

I acknowledge that I will be participating in the Homeownership Initiative Grant (HI) Program. This involves attending Pre-Purchase Counseling, Home Purchase Counseling (providing necessary documentation requested by the housing counseling agency), and Post-Purchase Counseling (returning for a follow-up housing counseling session between 6 and 12 months after purchasing an eligible home).

Initials

Intake Form English

Form

APPLICANT

CO APPLICANT

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

AUTHORIZATION & CERTIFICATION

I Request and Authorize NHS of Greater Berks to:

Client’s Certification:

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

MY PERSONAL INFORMATION AND COUNSELING SERVICES

Counseling Services Checklist

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:

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

How We Use Your Information:

Client Authorization

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

COUNSELING AGENCY DISCLOSURES

Please Initial

For Client:

Interested in learning more about what we can offer you?Get in touch with us today for more information!

Interested in learning more about what we can offer you?
Get in touch with us today for more information!