English Intake Form

Intake Form - English

Program *

APPLICANT

Citizenship Status
Gender *
First Time Home Buyer *
Handicapped *
Veteran *
Household Type *
If not working enter n/a
Education Level (please check one) *
Ethnicity Hispanic *
Race *

CO APPLICANT

Citizenship Status
Gender
First Time Home Buyer
Handicapped
Veteran
Household Type
Education Level (please check one)
Ethnicity Hispanic
Race

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

Referred By *
Are you currently working with a lender/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.

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 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

Please initial all items that are applicable

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Counseling Agency Information

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.
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):
CLIENT SIGNATURE(S):
DATE:

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

CLIENT ENGAGEMENT AGREEMENT

(This agreement is optional and does not impact the rest of the 3-in-1 form)

Today’s consumer is searching for real-time information on how to maneuver through the maze of financial products and services, establish or rebuild credit, reduce debt and save for the future. Helping clients reach their potential through a variety of services has never been more essential.

Financial counseling is an emerging field that supports clients as they work towards goals and strive to maximize their financial potential. Through an ongoing, systematic and collaborative process, coaches that specialize in financial capabilities can facilitate changes in clients’ financial habits so that they can reach financial security. Participating in a regimented course of financial counseling services can increase the client’s sense of well-being and safety through knowledge, and promote changing behaviors that will improve their financial circumstance.

If you are interested in improving your financial capabilities, please agree to the following:

I am willing to commit to at least four sessions (minimum of one hour per session) over the course of 12 months and a minimum of one follow-up survey within three months of the final session.

The first session must be a face-to-face session with a counselor. Upon submission of required documentation, subsequent sessions can be conducted using alternative methods of communication such as: telephone, internet, Skype, Smart Phone, etc.

I understand that my counselor will review and discuss an updated Action Plan for each session, and I will receive a copy.

CLIENT NAME(S):
CLIENT SIGNATURE(S):
DATE:

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

COUNSELING AGENCY DISCLOSURES

Please Initial

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This is only a request for programs and services - not a loan application.