English Intake Form

Intake Form - English
Preferred Language *
Program *

APPLICANT

Gender *
First Time Home Buyer *
Handicapped *
Veteran *
Current Housing Arrangement *
Household Type *
If not working enter n/a
If not working enter your phone number
Education Level (please check one) *
Ethnicity Hispanic *
Race *

CO APPLICANT

Gender
First Time Home Buyer
Handicapped
Veteran
Current Housing Arrangement
Household Type
Education Level (please check one)
Ethnicity Hispanic
Race

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

Referred By *

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
Time
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.

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

Initials
Initials
Initials
Initials
Initials
Initials
Initials
Initials
Initials
Initials
Initials
Initials
NHSGB Information

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: