{"id":2271,"date":"2020-01-18T18:03:24","date_gmt":"2020-01-18T23:03:24","guid":{"rendered":"https:\/\/nhsgreaterberks.org\/?page_id=2271"},"modified":"2024-03-20T19:28:06","modified_gmt":"2024-03-20T23:28:06","slug":"intake-form-english","status":"publish","type":"page","link":"https:\/\/nhsgb.org\/intake-form-english\/","title":{"rendered":"English Intake Form"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row css=&#8221;.vc_custom_1710977282026{margin-top: 30px !important;}&#8221;][vc_column][vc_column_text]<div class=\"frm_forms  with_frm_style frm_center_submit frm_style_formidable-style\" id=\"frm_form_24_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form intake-form frm_js_validate  frm_ajax_submit  frm_pro_form \" id=\"form_intake_form_english2\"  >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Intake Form - English<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"24\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_24\" id=\"frm_hide_fields_24\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"intake_form_english2\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_24\" name=\"frm_submit_entry_24\" value=\"6044d2454e\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/2271\" \/><div id=\"frm_field_1491_container\" class=\"frm_form_field frm_section_heading form-field  frm_hide_section\">\r\n<h3 class=\"frm_pos_none frm_section_spacing\"><\/h3>\r\n\r\n\r\n<div id=\"frm_field_1493_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_program frm_first horizontal_radio\">\r\n    <div  id=\"field_program3_label\" class=\"frm_primary_label\">Program\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_program3_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1493-1491-0\"><label for=\"field_program3-0\">\t\t<input type=\"radio\" name=\"item_meta[1493]\" id=\"field_program3-0\" value=\"CREDIT COUNSELING\"\n\t\t   data-sectionid=\"1491\" data-reqmsg=\"Program cannot be blank.\" data-invmsg=\"Program is invalid\" aria-invalid=\"false\"  \/> CREDIT COUNSELING<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1493-1491-1\"><label for=\"field_program3-1\">\t\t<input type=\"radio\" name=\"item_meta[1493]\" id=\"field_program3-1\" value=\"HOMEBUYER CLASS\"\n\t\t   data-sectionid=\"1491\" data-reqmsg=\"Program cannot be blank.\" data-invmsg=\"Program is invalid\" aria-invalid=\"false\"  \/> HOMEBUYER CLASS<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1493-1491-2\"><label for=\"field_program3-2\">\t\t<input type=\"radio\" name=\"item_meta[1493]\" id=\"field_program3-2\" value=\"CLOSING COST LOAN ASSISTANCE\"\n\t\t   data-sectionid=\"1491\" data-reqmsg=\"Program cannot be blank.\" data-invmsg=\"Program is invalid\" aria-invalid=\"false\"  \/> CLOSING COST LOAN ASSISTANCE<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1493-1491-3\"><label for=\"field_program3-3\">\t\t<input type=\"radio\" name=\"item_meta[1493]\" id=\"field_program3-3\" value=\"MY LIFE - REPAIR PROGRAM\"\n\t\t   data-sectionid=\"1491\" data-reqmsg=\"Program cannot be blank.\" data-invmsg=\"Program is invalid\" aria-invalid=\"false\"  \/> MY LIFE - REPAIR PROGRAM<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_1495_container\" class=\"frm_form_field frm_section_heading form-field  frm_full section-title no-margin\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">APPLICANT<\/h3>\r\n\r\n\r\n<div id=\"frm_field_1496_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_full_name3\" id=\"field_full_name3_label\" class=\"frm_primary_label\">Full Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_full_name3\" name=\"item_meta[1496]\" value=\"\"  data-sectionid=\"1495\" data-reqmsg=\"Full Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1497_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_email43\" id=\"field_email43_label\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_email43\" name=\"item_meta[1497]\" value=\"\"  data-sectionid=\"1495\" data-reqmsg=\"Email cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1498_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12\">\r\n    <label for=\"field_street43\" id=\"field_street43_label\" class=\"frm_primary_label\">Street\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_street43\" name=\"item_meta[1498]\" value=\"\"  data-sectionid=\"1495\" data-reqmsg=\"Street cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1500_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_third\">\r\n    <label for=\"field_city43\" id=\"field_city43_label\" class=\"frm_primary_label\">City\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_city43\" name=\"item_meta[1500]\" value=\"\"  data-sectionid=\"1495\" data-reqmsg=\"City cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1501_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_state43\" id=\"field_state43_label\" class=\"frm_primary_label\">State\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_state43\" name=\"item_meta[1501]\" value=\"\"  data-sectionid=\"1495\" maxlength=\"2\" data-reqmsg=\"State cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1502_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_zip_code43\" id=\"field_zip_code43_label\" class=\"frm_primary_label\">Zip Code\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_zip_code43\" name=\"item_meta[1502]\" value=\"\"  data-sectionid=\"1495\" data-reqmsg=\"Zip Code cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1506_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm_first\">\r\n    <label for=\"field_birth_date43\" id=\"field_birth_date43_label\" class=\"frm_primary_label\">Birth Date\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_birth_date43\" name=\"item_meta[1506]\" value=\"\"  data-sectionid=\"1495\" maxlength=\"10\" data-reqmsg=\"Birth Date cannot be blank.\" aria-required=\"true\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1503_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4\">\r\n    <label for=\"field_home_phone43\" id=\"field_home_phone43_label\" class=\"frm_primary_label\">Phone #\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_home_phone43\" name=\"item_meta[1503]\" value=\"\"  data-sectionid=\"1495\" data-reqmsg=\"Phone # cannot be blank.\" aria-required=\"true\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1505_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4\">\r\n    <label for=\"field_social_security_no3\" id=\"field_social_security_no3_label\" class=\"frm_primary_label\">Social Security #\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_social_security_no3\" name=\"item_meta[1505]\" value=\"\"  data-sectionid=\"1495\" data-reqmsg=\"Social Security # cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1510_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first horizontal_radio\">\r\n    <div  id=\"field_us_citizen2_label\" class=\"frm_primary_label\">Citizenship Status\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_us_citizen2_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1510-1495-0\"><label for=\"field_us_citizen2-0\">\t\t<input type=\"radio\" name=\"item_meta[1510]\" id=\"field_us_citizen2-0\" value=\"Citizen\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Citizenship Status cannot be blank.\" data-invmsg=\"Citizenship Status is invalid\" aria-invalid=\"false\"  \/> Citizen<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1510-1495-1\"><label for=\"field_us_citizen2-1\">\t\t<input type=\"radio\" name=\"item_meta[1510]\" id=\"field_us_citizen2-1\" value=\"Permanent Resident\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Citizenship Status cannot be blank.\" data-invmsg=\"Citizenship Status is invalid\" aria-invalid=\"false\"  \/> Permanent Resident<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1510-1495-2\"><label for=\"field_us_citizen2-2\">\t\t<input type=\"radio\" name=\"item_meta[1510]\" id=\"field_us_citizen2-2\" value=\"Non-Permanent Resident\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Citizenship Status cannot be blank.\" data-invmsg=\"Citizenship Status is invalid\" aria-invalid=\"false\"  \/> Non-Permanent Resident<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1507_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 horizontal_radio\">\r\n    <div  id=\"field_gender43_label\" class=\"frm_primary_label\">Gender\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_gender43_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1507-1495-0\"><label for=\"field_gender43-0\">\t\t<input type=\"radio\" name=\"item_meta[1507]\" id=\"field_gender43-0\" value=\"Male\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Gender cannot be blank.\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  \/> Male<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1507-1495-1\"><label for=\"field_gender43-1\">\t\t<input type=\"radio\" name=\"item_meta[1507]\" id=\"field_gender43-1\" value=\"Female\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Gender cannot be blank.\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  \/> Female<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1507-1495-2\"><label for=\"field_gender43-2\">\t\t<input type=\"radio\" name=\"item_meta[1507]\" id=\"field_gender43-2\" value=\"Other\/Non-Conforming\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Gender cannot be blank.\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  \/> Other\/Non-Conforming<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1512_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm_first horizontal_radio\">\r\n    <div  id=\"field_first_time_home_buyer33_label\" class=\"frm_primary_label\">First Time Home Buyer\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_first_time_home_buyer33_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1512-1495-0\"><label for=\"field_first_time_home_buyer33-0\">\t\t<input type=\"radio\" name=\"item_meta[1512]\" id=\"field_first_time_home_buyer33-0\" value=\"Yes\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"First Time Home Buyer cannot be blank.\" data-invmsg=\"First Time Home Buyer is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1512-1495-1\"><label for=\"field_first_time_home_buyer33-1\">\t\t<input type=\"radio\" name=\"item_meta[1512]\" id=\"field_first_time_home_buyer33-1\" value=\"No\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"First Time Home Buyer cannot be blank.\" data-invmsg=\"First Time Home Buyer is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1508_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 horizontal_radio\">\r\n    <div  id=\"field_handicapped43_label\" class=\"frm_primary_label\">Handicapped\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_handicapped43_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1508-1495-0\"><label for=\"field_handicapped43-0\">\t\t<input type=\"radio\" name=\"item_meta[1508]\" id=\"field_handicapped43-0\" value=\"Yes\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Handicapped cannot be blank.\" data-invmsg=\"Handicapped is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1508-1495-1\"><label for=\"field_handicapped43-1\">\t\t<input type=\"radio\" name=\"item_meta[1508]\" id=\"field_handicapped43-1\" value=\"No\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Handicapped cannot be blank.\" data-invmsg=\"Handicapped is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1509_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 horizontal_radio\">\r\n    <div  id=\"field_veteran43_label\" class=\"frm_primary_label\">Veteran\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_veteran43_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1509-1495-0\"><label for=\"field_veteran43-0\">\t\t<input type=\"radio\" name=\"item_meta[1509]\" id=\"field_veteran43-0\" value=\"Yes\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Veteran cannot be blank.\" data-invmsg=\"Veteran is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1509-1495-1\"><label for=\"field_veteran43-1\">\t\t<input type=\"radio\" name=\"item_meta[1509]\" id=\"field_veteran43-1\" value=\"No\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Veteran cannot be blank.\" data-invmsg=\"Veteran is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1515_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n    <div  id=\"field_household_type43_label\" class=\"frm_primary_label\">  Household Type\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_household_type43_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1515-1495-0\"><label for=\"field_household_type43-0\">\t\t<input type=\"radio\" name=\"item_meta[1515]\" id=\"field_household_type43-0\" value=\"Unmarried\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"  Household Type cannot be blank.\" data-invmsg=\"  Household Type is invalid\" aria-invalid=\"false\"  \/> Unmarried<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1515-1495-1\"><label for=\"field_household_type43-1\">\t\t<input type=\"radio\" name=\"item_meta[1515]\" id=\"field_household_type43-1\" value=\"Married\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"  Household Type cannot be blank.\" data-invmsg=\"  Household Type is invalid\" aria-invalid=\"false\"  \/> Married<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1515-1495-2\"><label for=\"field_household_type43-2\">\t\t<input type=\"radio\" name=\"item_meta[1515]\" id=\"field_household_type43-2\" value=\"Separated\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"  Household Type cannot be blank.\" data-invmsg=\"  Household Type is invalid\" aria-invalid=\"false\"  \/> Separated<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1516_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_fourth\">\r\n    <label for=\"field_family_size3\" id=\"field_family_size3_label\" class=\"frm_primary_label\">Family Size\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_family_size3\" name=\"item_meta[1516]\" value=\"\"  data-sectionid=\"1495\" data-reqmsg=\"Family Size cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1517_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_fourth\">\r\n    <label for=\"field_dependents3\" id=\"field_dependents3_label\" class=\"frm_primary_label\">Dependents\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_dependents3\" name=\"item_meta[1517]\" value=\"\"  data-sectionid=\"1495\" data-reqmsg=\"Dependents cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1518_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_fourth\">\r\n    <label for=\"field_monthly_income3\" id=\"field_monthly_income3_label\" class=\"frm_primary_label\">Monthly Income\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_monthly_income3\" name=\"item_meta[1518]\" value=\"\"  data-sectionid=\"1495\" data-reqmsg=\"Monthly Income cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1519_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_fourth\">\r\n    <label for=\"field_household_income3\" id=\"field_household_income3_label\" class=\"frm_primary_label\">Household Income\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_household_income3\" name=\"item_meta[1519]\" value=\"\"  data-sectionid=\"1495\" data-reqmsg=\"Household Income cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1520_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm_first\">\r\n    <label for=\"field_employer_name4\" id=\"field_employer_name4_label\" class=\"frm_primary_label\">Employer Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_employer_name4\" name=\"item_meta[1520]\" value=\"\"  data-sectionid=\"1495\" data-reqmsg=\"Employer Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_employer_name4\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_employer_name4\">If not working enter n\/a<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_1523_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4\">\r\n    <label for=\"field_hourly_rate4\" id=\"field_hourly_rate4_label\" class=\"frm_primary_label\">Hourly Rate\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_hourly_rate4\" name=\"item_meta[1523]\" value=\"\"  data-sectionid=\"1495\" data-reqmsg=\"Hourly Rate cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1524_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4\">\r\n    <label for=\"field_start_date2\" id=\"field_start_date2_label\" class=\"frm_primary_label\">Start Date\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_start_date2\" name=\"item_meta[1524]\" value=\"\"  data-sectionid=\"1495\" data-reqmsg=\"Start Date cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1525_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n    <div  id=\"field_education_level43_label\" class=\"frm_primary_label\">Education Level (please check one)\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_education_level43_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1525-1495-0\"><label for=\"field_education_level43-0\">\t\t<input type=\"radio\" name=\"item_meta[1525]\" id=\"field_education_level43-0\" value=\"Below High School\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Education Level (please check one) cannot be blank.\" data-invmsg=\"Education Level (please check one) is invalid\" aria-invalid=\"false\"  \/> Below High School<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1525-1495-1\"><label for=\"field_education_level43-1\">\t\t<input type=\"radio\" name=\"item_meta[1525]\" id=\"field_education_level43-1\" value=\"High School or Equivalent\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Education Level (please check one) cannot be blank.\" data-invmsg=\"Education Level (please check one) is invalid\" aria-invalid=\"false\"  \/> High School or Equivalent<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1525-1495-2\"><label for=\"field_education_level43-2\">\t\t<input type=\"radio\" name=\"item_meta[1525]\" id=\"field_education_level43-2\" value=\"Other\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Education Level (please check one) cannot be blank.\" data-invmsg=\"Education Level (please check one) is invalid\" aria-invalid=\"false\"  \/> Other<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1526_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n    <div  id=\"field_ethnicity_hispanic3_label\" class=\"frm_primary_label\">Ethnicity Hispanic\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_ethnicity_hispanic3_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1526-1495-0\"><label for=\"field_ethnicity_hispanic3-0\">\t\t<input type=\"radio\" name=\"item_meta[1526]\" id=\"field_ethnicity_hispanic3-0\" value=\"Yes\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Ethnicity Hispanic cannot be blank.\" data-invmsg=\"Ethnicity Hispanic is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1526-1495-1\"><label for=\"field_ethnicity_hispanic3-1\">\t\t<input type=\"radio\" name=\"item_meta[1526]\" id=\"field_ethnicity_hispanic3-1\" value=\"No\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Ethnicity Hispanic cannot be blank.\" data-invmsg=\"Ethnicity Hispanic is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1527_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first frm_radio_set frm_three_col\">\r\n    <div  id=\"field_race43_label\" class=\"frm_primary_label\">Race\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_race43_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1527-1495-0\"><label for=\"field_race43-0\">\t\t<input type=\"radio\" name=\"item_meta[1527]\" id=\"field_race43-0\" value=\"American Indian or Alaskan Native\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Race cannot be blank.\" data-invmsg=\"Race is invalid\" aria-invalid=\"false\"  \/> American Indian or Alaskan Native<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1527-1495-1\"><label for=\"field_race43-1\">\t\t<input type=\"radio\" name=\"item_meta[1527]\" id=\"field_race43-1\" value=\"Asian\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Race cannot be blank.\" data-invmsg=\"Race is invalid\" aria-invalid=\"false\"  \/> Asian<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1527-1495-2\"><label for=\"field_race43-2\">\t\t<input type=\"radio\" name=\"item_meta[1527]\" id=\"field_race43-2\" value=\"White\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Race cannot be blank.\" data-invmsg=\"Race is invalid\" aria-invalid=\"false\"  \/> White<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1527-1495-3\"><label for=\"field_race43-3\">\t\t<input type=\"radio\" name=\"item_meta[1527]\" id=\"field_race43-3\" value=\"Black or African American\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Race cannot be blank.\" data-invmsg=\"Race is invalid\" aria-invalid=\"false\"  \/> Black or African American<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1527-1495-4\"><label for=\"field_race43-4\">\t\t<input type=\"radio\" name=\"item_meta[1527]\" id=\"field_race43-4\" value=\"Black or African American &amp; White\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Race cannot be blank.\" data-invmsg=\"Race is invalid\" aria-invalid=\"false\"  \/> Black or African American &amp; White<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1527-1495-8\"><label for=\"field_race43-8\">\t\t<input type=\"radio\" name=\"item_meta[1527]\" id=\"field_race43-8\" value=\"Native Hawaiian or Other Pacific Islander\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Race cannot be blank.\" data-invmsg=\"Race is invalid\" aria-invalid=\"false\"  \/> Native Hawaiian or Other Pacific Islander<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1527-1495-11\"><label for=\"field_race43-11\">\t\t<input type=\"radio\" name=\"item_meta[1527]\" id=\"field_race43-11\" value=\"Chose Not to Respond\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Race cannot be blank.\" data-invmsg=\"Race is invalid\" aria-invalid=\"false\"  \/> Chose Not to Respond<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1527-1495-12\"><label for=\"field_race43-12\">\t\t<input type=\"radio\" name=\"item_meta[1527]\" id=\"field_race43-12\" value=\"Other\"\n\t\t   data-sectionid=\"1495\" data-reqmsg=\"Race cannot be blank.\" data-invmsg=\"Race is invalid\" aria-invalid=\"false\"  \/> Other<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1528_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first\">\r\n    <label for=\"field_race_other2\" id=\"field_race_other2_label\" class=\"frm_primary_label\">Enter your race\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_race_other2\" name=\"item_meta[1528]\" value=\"\"  data-sectionid=\"1495\" data-reqmsg=\"Enter your race cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_1530_container\" class=\"frm_form_field frm_section_heading form-field  frm_full  section-title\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">CO APPLICANT<\/h3>\r\n\r\n\r\n<div id=\"frm_field_1531_container\" class=\"frm_form_field form-field  frm_top_container frm_first frm_third\">\r\n    <label for=\"field_co_full_name4\" id=\"field_co_full_name4_label\" class=\"frm_primary_label\">Full Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_co_full_name4\" name=\"item_meta[1531]\" value=\"\"  data-sectionid=\"1530\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1532_container\" class=\"frm_form_field form-field  frm_top_container frm_third\">\r\n    <label for=\"field_relationship_to_applicant3\" id=\"field_relationship_to_applicant3_label\" class=\"frm_primary_label\">Relationship to Applicant\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_relationship_to_applicant3\" name=\"item_meta[1532]\" value=\"\"  data-sectionid=\"1530\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1533_container\" class=\"frm_form_field form-field  frm_top_container frm_third\">\r\n    <label for=\"field_co_email53\" id=\"field_co_email53_label\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_co_email53\" name=\"item_meta[1533]\" value=\"\"  data-sectionid=\"1530\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1534_container\" class=\"frm_form_field form-field  frm_top_container frm12 frm_first\">\r\n    <label for=\"field_co_street33\" id=\"field_co_street33_label\" class=\"frm_primary_label\">Street\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_co_street33\" name=\"item_meta[1534]\" value=\"\"  data-sectionid=\"1530\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1536_container\" class=\"frm_form_field form-field  frm_top_container frm_first frm_third\">\r\n    <label for=\"field_co_city53\" id=\"field_co_city53_label\" class=\"frm_primary_label\">City\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_co_city53\" name=\"item_meta[1536]\" value=\"\"  data-sectionid=\"1530\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1537_container\" class=\"frm_form_field form-field  frm_top_container frm_third\">\r\n    <label for=\"field_co_state53\" id=\"field_co_state53_label\" class=\"frm_primary_label\">State\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_co_state53\" name=\"item_meta[1537]\" value=\"\"  data-sectionid=\"1530\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1538_container\" class=\"frm_form_field form-field  frm_top_container frm_third\">\r\n    <label for=\"field_co_zip_code53\" id=\"field_co_zip_code53_label\" class=\"frm_primary_label\">Zip Code\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_co_zip_code53\" name=\"item_meta[1538]\" value=\"\"  data-sectionid=\"1530\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1542_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_first\">\r\n    <label for=\"field_co_birth_date43\" id=\"field_co_birth_date43_label\" class=\"frm_primary_label\">Birth Date\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_co_birth_date43\" name=\"item_meta[1542]\" value=\"\"  data-sectionid=\"1530\" maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1539_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n    <label for=\"field_co_home_phone53\" id=\"field_co_home_phone53_label\" class=\"frm_primary_label\">Phone #\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_co_home_phone53\" name=\"item_meta[1539]\" value=\"\"  data-sectionid=\"1530\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1541_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n    <label for=\"field_co_social_security_no4\" id=\"field_co_social_security_no4_label\" class=\"frm_primary_label\">Social Security #\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_co_social_security_no4\" name=\"item_meta[1541]\" value=\"\"  data-sectionid=\"1530\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1546_container\" class=\"frm_form_field form-field  frm_top_container frm6 frm_first horizontal_radio\">\r\n    <div  id=\"field_co_us_citizen2_label\" class=\"frm_primary_label\">Citizenship Status\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_co_us_citizen2_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1546-1530-0\"><label for=\"field_co_us_citizen2-0\">\t\t<input type=\"radio\" name=\"item_meta[1546]\" id=\"field_co_us_citizen2-0\" value=\"Citizen\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Citizenship Status is invalid\" aria-invalid=\"false\"  \/> Citizen<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1546-1530-1\"><label for=\"field_co_us_citizen2-1\">\t\t<input type=\"radio\" name=\"item_meta[1546]\" id=\"field_co_us_citizen2-1\" value=\"Permanent Resident\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Citizenship Status is invalid\" aria-invalid=\"false\"  \/> Permanent Resident<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1546-1530-2\"><label for=\"field_co_us_citizen2-2\">\t\t<input type=\"radio\" name=\"item_meta[1546]\" id=\"field_co_us_citizen2-2\" value=\"Non-Permanent Resident\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Citizenship Status is invalid\" aria-invalid=\"false\"  \/> Non-Permanent Resident<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1543_container\" class=\"frm_form_field form-field  frm_top_container frm6 horizontal_radio\">\r\n    <div  id=\"field_co_gender43_label\" class=\"frm_primary_label\">Gender\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_co_gender43_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1543-1530-0\"><label for=\"field_co_gender43-0\">\t\t<input type=\"radio\" name=\"item_meta[1543]\" id=\"field_co_gender43-0\" value=\"Male\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  \/> Male<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1543-1530-1\"><label for=\"field_co_gender43-1\">\t\t<input type=\"radio\" name=\"item_meta[1543]\" id=\"field_co_gender43-1\" value=\"Female\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  \/> Female<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1543-1530-2\"><label for=\"field_co_gender43-2\">\t\t<input type=\"radio\" name=\"item_meta[1543]\" id=\"field_co_gender43-2\" value=\"Other\/Non-Conforming\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  \/> Other\/Non-Conforming<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1548_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_first horizontal_radio\">\r\n    <div  id=\"field_co_first_time_home_buyer43_label\" class=\"frm_primary_label\">First Time Home Buyer\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_co_first_time_home_buyer43_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1548-1530-0\"><label for=\"field_co_first_time_home_buyer43-0\">\t\t<input type=\"radio\" name=\"item_meta[1548]\" id=\"field_co_first_time_home_buyer43-0\" value=\"Yes\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"First Time Home Buyer is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1548-1530-1\"><label for=\"field_co_first_time_home_buyer43-1\">\t\t<input type=\"radio\" name=\"item_meta[1548]\" id=\"field_co_first_time_home_buyer43-1\" value=\"No\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"First Time Home Buyer is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1544_container\" class=\"frm_form_field form-field  frm_top_container frm4 horizontal_radio\">\r\n    <div  id=\"field_co_handicapped43_label\" class=\"frm_primary_label\">Handicapped\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_co_handicapped43_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1544-1530-0\"><label for=\"field_co_handicapped43-0\">\t\t<input type=\"radio\" name=\"item_meta[1544]\" id=\"field_co_handicapped43-0\" value=\"Yes\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Handicapped is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1544-1530-1\"><label for=\"field_co_handicapped43-1\">\t\t<input type=\"radio\" name=\"item_meta[1544]\" id=\"field_co_handicapped43-1\" value=\"No\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Handicapped is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1545_container\" class=\"frm_form_field form-field  frm_top_container frm4 horizontal_radio\">\r\n    <div  id=\"field_co_veteran33_label\" class=\"frm_primary_label\">Veteran\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_co_veteran33_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1545-1530-0\"><label for=\"field_co_veteran33-0\">\t\t<input type=\"radio\" name=\"item_meta[1545]\" id=\"field_co_veteran33-0\" value=\"Yes\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Veteran is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1545-1530-1\"><label for=\"field_co_veteran33-1\">\t\t<input type=\"radio\" name=\"item_meta[1545]\" id=\"field_co_veteran33-1\" value=\"No\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Veteran is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1551_container\" class=\"frm_form_field form-field  frm_top_container horizontal_radio\">\r\n    <div  id=\"field_co_household_type4_label\" class=\"frm_primary_label\">Household Type\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_co_household_type4_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1551-1530-0\"><label for=\"field_co_household_type4-0\">\t\t<input type=\"radio\" name=\"item_meta[1551]\" id=\"field_co_household_type4-0\" value=\"Unmarried\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Household Type is invalid\" aria-invalid=\"false\"  \/> Unmarried<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1551-1530-1\"><label for=\"field_co_household_type4-1\">\t\t<input type=\"radio\" name=\"item_meta[1551]\" id=\"field_co_household_type4-1\" value=\"Married\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Household Type is invalid\" aria-invalid=\"false\"  \/> Married<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1551-1530-2\"><label for=\"field_co_household_type4-2\">\t\t<input type=\"radio\" name=\"item_meta[1551]\" id=\"field_co_household_type4-2\" value=\"Separated\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Household Type is invalid\" aria-invalid=\"false\"  \/> Separated<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1552_container\" class=\"frm_form_field form-field  frm_top_container frm_first frm_fourth\">\r\n    <label for=\"field_co_family_size4\" id=\"field_co_family_size4_label\" class=\"frm_primary_label\">Family Size\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_co_family_size4\" name=\"item_meta[1552]\" value=\"\"  data-sectionid=\"1530\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1553_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_co_dependents4\" id=\"field_co_dependents4_label\" class=\"frm_primary_label\">Dependents\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_co_dependents4\" name=\"item_meta[1553]\" value=\"\"  data-sectionid=\"1530\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1554_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_co_monthly_income4\" id=\"field_co_monthly_income4_label\" class=\"frm_primary_label\">Monthly Income\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_co_monthly_income4\" name=\"item_meta[1554]\" value=\"\"  data-sectionid=\"1530\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1555_container\" class=\"frm_form_field form-field  frm_top_container frm_fourth\">\r\n    <label for=\"field_co_household_income3\" id=\"field_co_household_income3_label\" class=\"frm_primary_label\">Household Income\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_co_household_income3\" name=\"item_meta[1555]\" value=\"\"  data-sectionid=\"1530\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1556_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_first\">\r\n    <label for=\"field_co_employer_name4\" id=\"field_co_employer_name4_label\" class=\"frm_primary_label\">Employer Name\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_co_employer_name4\" name=\"item_meta[1556]\" value=\"\"  data-sectionid=\"1530\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1559_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n    <label for=\"field_co_hourly_rate4\" id=\"field_co_hourly_rate4_label\" class=\"frm_primary_label\">Hourly Rate\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_co_hourly_rate4\" name=\"item_meta[1559]\" value=\"\"  data-sectionid=\"1530\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1560_container\" class=\"frm_form_field form-field  frm_top_container frm6 frm12 frm4\">\r\n    <label for=\"field_co_start_date2\" id=\"field_co_start_date2_label\" class=\"frm_primary_label\">Start Date\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_co_start_date2\" name=\"item_meta[1560]\" value=\"\"  data-sectionid=\"1530\" data-invmsg=\"Text is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1561_container\" class=\"frm_form_field form-field  frm_top_container horizontal_radio\">\r\n    <div  id=\"field_co_education_level4_label\" class=\"frm_primary_label\">Education Level (please check one)\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_co_education_level4_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1561-1530-0\"><label for=\"field_co_education_level4-0\">\t\t<input type=\"radio\" name=\"item_meta[1561]\" id=\"field_co_education_level4-0\" value=\"Below High School\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Education Level (please check one) is invalid\" aria-invalid=\"false\"  \/> Below High School<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1561-1530-1\"><label for=\"field_co_education_level4-1\">\t\t<input type=\"radio\" name=\"item_meta[1561]\" id=\"field_co_education_level4-1\" value=\"High School or Equivalent\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Education Level (please check one) is invalid\" aria-invalid=\"false\"  \/> High School or Equivalent<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1561-1530-2\"><label for=\"field_co_education_level4-2\">\t\t<input type=\"radio\" name=\"item_meta[1561]\" id=\"field_co_education_level4-2\" value=\"Other\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Education Level (please check one) is invalid\" aria-invalid=\"false\"  \/> Other<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1562_container\" class=\"frm_form_field form-field  frm_top_container horizontal_radio\">\r\n    <div  id=\"field_co_ethnicity_hispanic4_label\" class=\"frm_primary_label\">Ethnicity Hispanic\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_co_ethnicity_hispanic4_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1562-1530-0\"><label for=\"field_co_ethnicity_hispanic4-0\">\t\t<input type=\"radio\" name=\"item_meta[1562]\" id=\"field_co_ethnicity_hispanic4-0\" value=\"Yes\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Ethnicity Hispanic is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1562-1530-1\"><label for=\"field_co_ethnicity_hispanic4-1\">\t\t<input type=\"radio\" name=\"item_meta[1562]\" id=\"field_co_ethnicity_hispanic4-1\" value=\"No\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Ethnicity Hispanic is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1563_container\" class=\"frm_form_field form-field  frm_top_container frm_three_col\">\r\n    <div  id=\"field_co_race43_label\" class=\"frm_primary_label\">Race\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_co_race43_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1563-1530-0\"><label for=\"field_co_race43-0\">\t\t<input type=\"radio\" name=\"item_meta[1563]\" id=\"field_co_race43-0\" value=\"American Indian or Alaskan Native\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Race is invalid\" aria-invalid=\"false\"  \/> American Indian or Alaskan Native<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1563-1530-1\"><label for=\"field_co_race43-1\">\t\t<input type=\"radio\" name=\"item_meta[1563]\" id=\"field_co_race43-1\" value=\"Asian\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Race is invalid\" aria-invalid=\"false\"  \/> Asian<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1563-1530-2\"><label for=\"field_co_race43-2\">\t\t<input type=\"radio\" name=\"item_meta[1563]\" id=\"field_co_race43-2\" value=\"White\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Race is invalid\" aria-invalid=\"false\"  \/> White<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1563-1530-3\"><label for=\"field_co_race43-3\">\t\t<input type=\"radio\" name=\"item_meta[1563]\" id=\"field_co_race43-3\" value=\"Black or African American\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Race is invalid\" aria-invalid=\"false\"  \/> Black or African American<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1563-1530-4\"><label for=\"field_co_race43-4\">\t\t<input type=\"radio\" name=\"item_meta[1563]\" id=\"field_co_race43-4\" value=\"Black or African American &amp; White\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Race is invalid\" aria-invalid=\"false\"  \/> Black or African American &amp; White<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1563-1530-5\"><label for=\"field_co_race43-5\">\t\t<input type=\"radio\" name=\"item_meta[1563]\" id=\"field_co_race43-5\" value=\"Native Hawaiian or Other Pacific Islander\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Race is invalid\" aria-invalid=\"false\"  \/> Native Hawaiian or Other Pacific Islander<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1563-1530-11\"><label for=\"field_co_race43-11\">\t\t<input type=\"radio\" name=\"item_meta[1563]\" id=\"field_co_race43-11\" value=\"Chose Not to Respond\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Race is invalid\" aria-invalid=\"false\"  \/> Chose Not to Respond<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1563-1530-13\"><label for=\"field_co_race43-13\">\t\t<input type=\"radio\" name=\"item_meta[1563]\" id=\"field_co_race43-13\" value=\"Other\"\n\t\t   data-sectionid=\"1530\" data-invmsg=\"Race is invalid\" aria-invalid=\"false\"  \/> Other<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1564_container\" class=\"frm_form_field form-field  frm_top_container frm12 frm_first\">\r\n    <label for=\"field_co_race_other2\" id=\"field_co_race_other2_label\" class=\"frm_primary_label\">Enter your race\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_co_race_other2\" name=\"item_meta[1564]\" value=\"\"  data-sectionid=\"1530\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_1571_container\" class=\"frm_form_field frm_section_heading form-field  frm_full section-title\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">REFERRED TO HOMEOWNERSHIP CENTER BY: (PLEASE CHECK ALL THAT APPLY)<\/h3>\r\n\r\n\r\n<div id=\"frm_field_1572_container\" class=\"frm_form_field form-field  frm_required_field frm_hidden_container frm_full frm_three_col\">\r\n    <div  id=\"field_referred_by3_label\" class=\"frm_primary_label\">Referred By\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_referred_by3_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1572-1571-0\"><label for=\"field_referred_by3-0\"><input type=\"checkbox\" name=\"item_meta[1572][]\" id=\"field_referred_by3-0\" value=\"Walk in\"  data-sectionid=\"1571\" data-frmlimit=\"9\"  data-reqmsg=\"Referred By cannot be blank.\" data-invmsg=\"Referred By is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> Walk in<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1572-1571-1\"><label for=\"field_referred_by3-1\"><input type=\"checkbox\" name=\"item_meta[1572][]\" id=\"field_referred_by3-1\" value=\"NHS Website\"  data-sectionid=\"1571\" data-frmlimit=\"9\"  data-reqmsg=\"Referred By cannot be blank.\" data-invmsg=\"Referred By is invalid\" aria-invalid=\"false\"   \/> NHS Website<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1572-1571-2\"><label for=\"field_referred_by3-2\"><input type=\"checkbox\" name=\"item_meta[1572][]\" id=\"field_referred_by3-2\" value=\"Facebook\"  data-sectionid=\"1571\" data-frmlimit=\"9\"  data-reqmsg=\"Referred By cannot be blank.\" data-invmsg=\"Referred By is invalid\" aria-invalid=\"false\"   \/> Facebook<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1572-1571-3\"><label for=\"field_referred_by3-3\"><input type=\"checkbox\" name=\"item_meta[1572][]\" id=\"field_referred_by3-3\" value=\"Friend or Family\"  data-sectionid=\"1571\" data-frmlimit=\"9\"  data-reqmsg=\"Referred By cannot be blank.\" data-invmsg=\"Referred By is invalid\" aria-invalid=\"false\"   \/> Friend or Family<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1572-1571-6\"><label for=\"field_referred_by3-6\"><input type=\"checkbox\" name=\"item_meta[1572][]\" id=\"field_referred_by3-6\" value=\"Lender\"  data-sectionid=\"1571\" data-frmlimit=\"9\"  data-reqmsg=\"Referred By cannot be blank.\" data-invmsg=\"Referred By is invalid\" aria-invalid=\"false\"   \/> Lender<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1572-1571-7\"><label for=\"field_referred_by3-7\"><input type=\"checkbox\" name=\"item_meta[1572][]\" id=\"field_referred_by3-7\" value=\"Realtor\"  data-sectionid=\"1571\" data-frmlimit=\"9\"  data-reqmsg=\"Referred By cannot be blank.\" data-invmsg=\"Referred By is invalid\" aria-invalid=\"false\"   \/> Realtor<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_1572-1571-8\"><label for=\"field_referred_by3-8\"><input type=\"checkbox\" name=\"item_meta[1572][]\" id=\"field_referred_by3-8\" value=\"Other\"  data-sectionid=\"1571\" data-frmlimit=\"9\"  data-reqmsg=\"Referred By cannot be blank.\" data-invmsg=\"Referred By is invalid\" aria-invalid=\"false\"   \/> Other<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1567_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first horizontal_radio\">\r\n    <div  id=\"field_working_with_lender2_label\" class=\"frm_primary_label\">Are you currently working with a lender\/bank\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_working_with_lender2_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_1567-1571-0\"><label for=\"field_working_with_lender2-0\">\t\t<input type=\"radio\" name=\"item_meta[1567]\" id=\"field_working_with_lender2-0\" value=\"Yes\"\n\t\t   data-sectionid=\"1571\" data-reqmsg=\"Are you currently working with a lender\/bank cannot be blank.\" data-invmsg=\"Are you currently working with a lender\/bank is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1567-1571-1\"><label for=\"field_working_with_lender2-1\">\t\t<input type=\"radio\" name=\"item_meta[1567]\" id=\"field_working_with_lender2-1\" value=\"No\"\n\t\t   data-sectionid=\"1571\" data-reqmsg=\"Are you currently working with a lender\/bank cannot be blank.\" data-invmsg=\"Are you currently working with a lender\/bank is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1568_container\" class=\"frm_form_field form-field  frm_top_container frm6\">\r\n    <label for=\"field_name_of_bank2\" id=\"field_name_of_bank2_label\" class=\"frm_primary_label\">Name of Bank\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_name_of_bank2\" name=\"item_meta[1568]\" value=\"\"  data-sectionid=\"1571\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_1577_container\" class=\"frm_form_field frm_section_heading form-field  frm_full section-title\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">AUTHORIZATION & CERTIFICATION<\/h3>\r\n\r\n\r\n<div id=\"frm_field_1578_container\" class=\"frm_form_field  frm_full frm_html_container form-field\">\n<h4>I Request and Authorize NHS of Greater Berks to:<\/h4>\n<p>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.<\/p>\n<h4>Client\u2019s Certification:<\/h4>\n<p>I\/We certify that the information included in this form is accurate and complete to the best of my\/our knowledge and belief.<\/p><\/div>\n<div id=\"frm_field_1583_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_two_thirds frm_sig\">\r\n    <label for=\"field_applicant_signature3\" id=\"field_applicant_signature3_label\" class=\"frm_primary_label\">Applicant Signature\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <div class=\"sigPad\" id=\"sigPad1583\" style=\"max-width:400px;\">\n\t<div class=\"sig sigWrapper\" style=\"height:100px;border-color:#cccccc;--bg-color:#ffffff;--active:#008ec2;--inactive:#dddddd;--active-text:#ffffff;--inactive-text:#ffffff;--button-margin:10px;--button-size:16px;--button-padding:8px;--button-side-margin:20px\">\n\t\t\t\t<ul class=\"sigNav\">\n\t\t\t<li class=\"drawIt\"><a href=\"#\" class=\"current\" title=\"Draw It\" aria-label=\"Draw It\"><i class=\"fas fa-pencil-alt\" aria-hidden><\/i><\/a><\/li>\n\t\t\t<li class=\"typeIt\"><a href=\"#\" title=\"Type It\" aria-label=\"Type It\"><i class=\"far fa-keyboard\" aria-hidden><\/i><\/a><\/li>\n\t\t<\/ul>\n\t\t\t\t<div class=\"typed\">\n\t\t\t<input type=\"text\" name=\"item_meta[1583][typed]\" class=\"name\" id=\"field_applicant_signature3\" autocomplete=\"off\" value=\"\" \/>\n\t\t<\/div>\n\t\t<canvas class=\"pad\" width=\"396\" height=\"100\"><\/canvas>\n\t\t<div class=\"clearButton\"><a href=\"#clear\">Clear<\/a><\/div>\n\t\t<input type=\"hidden\" name=\"item_meta[1583][output]\" class=\"output\" value=\"\" \/>\n\t<\/div>\n<\/div>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1584_container\" class=\"frm_form_field form-field  frm_top_container frm_third frm_signature_sibling\">\r\n    <label for=\"field_applicant_signature_date3\" id=\"field_applicant_signature_date3_label\" class=\"frm_primary_label\">Date\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_applicant_signature_date3\" name=\"item_meta[1584]\" value=\"\"  data-sectionid=\"1577\" maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1585_container\" class=\"frm_form_field form-field  frm_top_container frm_first frm_two_thirds frm_sig\">\r\n    <label for=\"field_co_applicant_signature3\" id=\"field_co_applicant_signature3_label\" class=\"frm_primary_label\">Co-Applicant Signature\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"sigPad\" id=\"sigPad1585\" style=\"max-width:400px;\">\n\t<div class=\"sig sigWrapper\" style=\"height:100px;border-color:#cccccc;--bg-color:#ffffff;--active:#008ec2;--inactive:#dddddd;--active-text:#ffffff;--inactive-text:#ffffff;--button-margin:10px;--button-size:16px;--button-padding:8px;--button-side-margin:20px\">\n\t\t\t\t<ul class=\"sigNav\">\n\t\t\t<li class=\"drawIt\"><a href=\"#\" class=\"current\" title=\"Draw It\" aria-label=\"Draw It\"><i class=\"fas fa-pencil-alt\" aria-hidden><\/i><\/a><\/li>\n\t\t\t<li class=\"typeIt\"><a href=\"#\" title=\"Type It\" aria-label=\"Type It\"><i class=\"far fa-keyboard\" aria-hidden><\/i><\/a><\/li>\n\t\t<\/ul>\n\t\t\t\t<div class=\"typed\">\n\t\t\t<input type=\"text\" name=\"item_meta[1585][typed]\" class=\"name\" id=\"field_co_applicant_signature3\" autocomplete=\"off\" value=\"\" \/>\n\t\t<\/div>\n\t\t<canvas class=\"pad\" width=\"396\" height=\"100\"><\/canvas>\n\t\t<div class=\"clearButton\"><a href=\"#clear\">Clear<\/a><\/div>\n\t\t<input type=\"hidden\" name=\"item_meta[1585][output]\" class=\"output\" value=\"\" \/>\n\t<\/div>\n<\/div>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1586_container\" class=\"frm_form_field form-field  frm_top_container frm_third frm_signature_sibling\">\r\n    <label for=\"field_co_applicant_signature_date3\" id=\"field_co_applicant_signature_date3_label\" class=\"frm_primary_label\">Date\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_co_applicant_signature_date3\" name=\"item_meta[1586]\" value=\"\"  data-sectionid=\"1577\" maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_1758_container\" class=\"frm_form_field frm_section_heading form-field  frm_full frm_adp section-title\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">AUTHORIZATION, DISCLOSURE, PRIVACY STATEMENT (3-in-1)<\/h3>\r\n\r\n\r\n<div id=\"frm_field_1760_container\" class=\"frm_form_field  frm_full frm_html_container form-field\">\n<h4>MY PERSONAL INFORMATION AND COUNSELING SERVICES<\/h4>\n<p>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.<\/p>\n<p>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.<\/p>\n<p>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.<\/p>\n<p>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.<\/p>\n<h5><u>Counseling Services Checklist<\/u><\/h5>\n<p>Please <u>initial<\/u> all items that are applicable<\/div>\n<div id=\"frm_field_1761_container\" class=\"frm_form_field form-field  frm_left_container frm12 frm_initials frm_first\">\r\n    <label for=\"field_5fbtq\" id=\"field_5fbtq_label\" class=\"frm_primary_label\">I have been verbally advised of the fee schedule, if any, prior to services being provided\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_input_group frm_with_box frm_with_post\"><input type=\"text\" id=\"field_5fbtq\" name=\"item_meta[1761]\" value=\"\"  data-sectionid=\"1758\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/><span class=\"frm_inline_box\">Initials<\/span><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1839_container\" class=\"frm_form_field form-field  frm_left_container frm12 frm_initials\">\r\n    <label for=\"field_9ef6q\" id=\"field_9ef6q_label\" class=\"frm_primary_label\">I have discussed Home Buyer Options and related Pre-Purchase topics and I have received the HUD forms: \u201cTen Important Questions to Ask Your Home Inspector\u201d & \u201cFor Your Protection: Get a Home Inspection\u201d\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_input_group frm_with_box frm_with_post\"><input type=\"text\" id=\"field_9ef6q\" name=\"item_meta[1839]\" value=\"\"  data-sectionid=\"1758\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/><span class=\"frm_inline_box\">Initials<\/span><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1840_container\" class=\"frm_form_field form-field  frm_left_container frm12 frm_initials\">\r\n    <label for=\"field_hzb1p\" id=\"field_hzb1p_label\" class=\"frm_primary_label\">I have received and reviewed a copy of the Fair Housing Pamphlet\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_input_group frm_with_box frm_with_post\"><input type=\"text\" id=\"field_hzb1p\" name=\"item_meta[1840]\" value=\"\"  data-sectionid=\"1758\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/><span class=\"frm_inline_box\">Initials<\/span><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1762_container\" class=\"frm_form_field form-field  frm_left_container frm_full frm_initials\">\r\n    <label for=\"field_vf7ah\" id=\"field_vf7ah_label\" class=\"frm_primary_label\">I understand that the counselor will discuss my budget with me, and I will receive a copy of my Budget\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_input_group frm_with_box frm_with_post\"><input type=\"text\" id=\"field_vf7ah\" name=\"item_meta[1762]\" value=\"\"  data-sectionid=\"1758\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/><span class=\"frm_inline_box\">Initials<\/span><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1763_container\" class=\"frm_form_field form-field  frm_left_container frm_full frm_initials\">\r\n    <label for=\"field_z7hwu\" id=\"field_z7hwu_label\" class=\"frm_primary_label\">I understand that the counselor will discuss my Action Plan with me, and I will receive a copy of my Action Plan\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_input_group frm_with_box frm_with_post\"><input type=\"text\" id=\"field_z7hwu\" name=\"item_meta[1763]\" value=\"\"  data-sectionid=\"1758\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/><span class=\"frm_inline_box\">Initials<\/span><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1764_container\" class=\"frm_form_field form-field  frm_left_container frm_full frm_initials\">\r\n    <label for=\"field_8prq4\" id=\"field_8prq4_label\" class=\"frm_primary_label\">I understand the counselor will explain the next steps needed to reach my financial goal to my satisfaction\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_input_group frm_with_box frm_with_post\"><input type=\"text\" id=\"field_8prq4\" name=\"item_meta[1764]\" value=\"\"  data-sectionid=\"1758\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/><span class=\"frm_inline_box\">Initials<\/span><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1765_container\" class=\"frm_form_field form-field  frm_left_container frm_full frm_initials\">\r\n    <label for=\"field_a4ugy\" id=\"field_a4ugy_label\" class=\"frm_primary_label\">Homebuyer Counseling\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_input_group frm_with_box frm_with_post\"><input type=\"text\" id=\"field_a4ugy\" name=\"item_meta[1765]\" value=\"\"  data-sectionid=\"1758\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/><span class=\"frm_inline_box\">Initials<\/span><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1766_container\" class=\"frm_form_field form-field  frm_left_container frm_full frm_initials\">\r\n    <label for=\"field_kydup\" id=\"field_kydup_label\" class=\"frm_primary_label\">Homebuyer Education\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_input_group frm_with_box frm_with_post\"><input type=\"text\" id=\"field_kydup\" name=\"item_meta[1766]\" value=\"\"  data-sectionid=\"1758\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/><span class=\"frm_inline_box\">Initials<\/span><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1767_container\" class=\"frm_form_field form-field  frm_left_container frm_full frm_initials\">\r\n    <label for=\"field_ftb4t\" id=\"field_ftb4t_label\" class=\"frm_primary_label\">Homeowner Counseling\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_input_group frm_with_box frm_with_post\"><input type=\"text\" id=\"field_ftb4t\" name=\"item_meta[1767]\" value=\"\"  data-sectionid=\"1758\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/><span class=\"frm_inline_box\">Initials<\/span><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1768_container\" class=\"frm_form_field form-field  frm_left_container frm_full frm_initials\">\r\n    <label for=\"field_jegbj\" id=\"field_jegbj_label\" class=\"frm_primary_label\">Homeowner Education\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_input_group frm_with_box frm_with_post\"><input type=\"text\" id=\"field_jegbj\" name=\"item_meta[1768]\" value=\"\"  data-sectionid=\"1758\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/><span class=\"frm_inline_box\">Initials<\/span><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1841_container\" class=\"frm_form_field form-field  frm_left_container frm_full frm_initials\">\r\n    <label for=\"field_o4dgt\" id=\"field_o4dgt_label\" class=\"frm_primary_label\">Delinquency and Default Counseling\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_input_group frm_with_box frm_with_post\"><input type=\"text\" id=\"field_o4dgt\" name=\"item_meta[1841]\" value=\"\"  data-sectionid=\"1758\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/><span class=\"frm_inline_box\">Initials<\/span><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1842_container\" class=\"frm_form_field form-field  frm_left_container frm_full frm_initials\">\r\n    <label for=\"field_qp437\" id=\"field_qp437_label\" class=\"frm_primary_label\">Delinquency and Default Education\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_input_group frm_with_box frm_with_post\"><input type=\"text\" id=\"field_qp437\" name=\"item_meta[1842]\" value=\"\"  data-sectionid=\"1758\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/><span class=\"frm_inline_box\">Initials<\/span><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1843_container\" class=\"frm_form_field form-field  frm_left_container frm_full frm_initials\">\r\n    <label for=\"field_6nab9\" id=\"field_6nab9_label\" class=\"frm_primary_label\">Reverse Mortgage Counseling\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_input_group frm_with_box frm_with_post\"><input type=\"text\" id=\"field_6nab9\" name=\"item_meta[1843]\" value=\"\"  data-sectionid=\"1758\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/><span class=\"frm_inline_box\">Initials<\/span><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1844_container\" class=\"frm_form_field form-field  frm_left_container frm_full frm_initials\">\r\n    <label for=\"field_rtjd6\" id=\"field_rtjd6_label\" class=\"frm_primary_label\">Fair Housing Education\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_input_group frm_with_box frm_with_post\"><input type=\"text\" id=\"field_rtjd6\" name=\"item_meta[1844]\" value=\"\"  data-sectionid=\"1758\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/><span class=\"frm_inline_box\">Initials<\/span><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1845_container\" class=\"frm_form_field form-field  frm_left_container frm_full frm_initials\">\r\n    <label for=\"field_69dao\" id=\"field_69dao_label\" class=\"frm_primary_label\">Tenant Counseling\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_input_group frm_with_box frm_with_post\"><input type=\"text\" id=\"field_69dao\" name=\"item_meta[1845]\" value=\"\"  data-sectionid=\"1758\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/><span class=\"frm_inline_box\">Initials<\/span><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1846_container\" class=\"frm_form_field form-field  frm_left_container frm_full frm_initials\">\r\n    <label for=\"field_m8h2p\" id=\"field_m8h2p_label\" class=\"frm_primary_label\">Homelessness and Displacement Counseling\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_input_group frm_with_box frm_with_post\"><input type=\"text\" id=\"field_m8h2p\" name=\"item_meta[1846]\" value=\"\"  data-sectionid=\"1758\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/><span class=\"frm_inline_box\">Initials<\/span><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1769_container\" class=\"frm_form_field form-field  frm_left_container frm_full frm_initials\">\r\n    <label for=\"field_cvl77\" id=\"field_cvl77_label\" class=\"frm_primary_label\">I want to buy a home in the next six (6) months\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_input_group frm_with_box frm_with_post\"><input type=\"text\" id=\"field_cvl77\" name=\"item_meta[1769]\" value=\"\"  data-sectionid=\"1758\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/><span class=\"frm_inline_box\">Initials<\/span><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1770_container\" class=\"frm_form_field form-field  frm_left_container frm_full frm_initials\">\r\n    <label for=\"field_xlwhf\" id=\"field_xlwhf_label\" class=\"frm_primary_label\">I want to buy a home, but not in the next six (6) months\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_input_group frm_with_box frm_with_post\"><input type=\"text\" id=\"field_xlwhf\" name=\"item_meta[1770]\" value=\"\"  data-sectionid=\"1758\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/><span class=\"frm_inline_box\">Initials<\/span><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1771_container\" class=\"frm_form_field form-field  frm_left_container frm_full frm_initials\">\r\n    <label for=\"field_dloc9\" id=\"field_dloc9_label\" class=\"frm_primary_label\">Other programs, services, or products\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_input_group frm_with_box frm_with_post\"><input type=\"text\" id=\"field_dloc9\" name=\"item_meta[1771]\" value=\"\"  data-sectionid=\"1758\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/><span class=\"frm_inline_box\">Initials<\/span><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1773_container\" class=\"frm_form_field  frm_full frm_html_container form-field\">\n<h5><u>Counseling Agency Information<\/u><\/h5>\n<\/div>\n<div id=\"frm_field_1774_container\" class=\"frm_form_field form-field  frm_left_container frm_first frm_two_thirds frm_hnsgb_info\">\r\n    <label for=\"field_qeei\" id=\"field_qeei_label\" class=\"frm_primary_label\">Counselor Name\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_qeei\" name=\"item_meta[1774]\" value=\"\"  data-sectionid=\"1758\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1775_container\" class=\"frm_form_field form-field  frm_left_container frm_third frm_hnsgb_info\">\r\n    <label for=\"field_t7jjq\" id=\"field_t7jjq_label\" class=\"frm_primary_label\">Phone\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_t7jjq\" name=\"item_meta[1775]\" value=\"610-372-8433  \"  readonly=\"readonly\"  data-sectionid=\"1758\" data-frmval=\"610-372-8433  \" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1776_container\" class=\"frm_form_field form-field  frm_left_container frm_first frm_two_thirds frm_hnsgb_info\">\r\n    <label for=\"field_uk375\" id=\"field_uk375_label\" class=\"frm_primary_label\">Counseling Agency\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_uk375\" name=\"item_meta[1776]\" value=\"Neighborhood Housing Services of Greater Berks, Inc.\"  readonly=\"readonly\"  data-sectionid=\"1758\" data-frmval=\"Neighborhood Housing Services of Greater Berks, Inc.\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1777_container\" class=\"frm_form_field form-field  frm_left_container frm_third frm_hnsgb_info\">\r\n    <label for=\"field_ohoa\" id=\"field_ohoa_label\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_ohoa\" name=\"item_meta[1777]\" value=\"\"  data-sectionid=\"1758\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1780_container\" class=\"frm_form_field form-field  frm_left_container frm_first frm_two_thirds frm_hnsgb_info\">\r\n    <label for=\"field_hm3xv\" id=\"field_hm3xv_label\" class=\"frm_primary_label\">RX Client Number\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_hm3xv\" name=\"item_meta[1780]\" value=\"\"  data-sectionid=\"1758\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1778_container\" class=\"frm_form_field form-field  frm_left_container frm_third frm_hnsgb_info\">\r\n    <label for=\"field_9s7cz\" id=\"field_9s7cz_label\" class=\"frm_primary_label\">Fax\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_9s7cz\" name=\"item_meta[1778]\" value=\"610-374-2866\"  readonly=\"readonly\"  data-sectionid=\"1758\" data-frmval=\"610-374-2866\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_1782_container\" class=\"frm_form_field frm_section_heading form-field  frm12 frm_adp frm_first section-title\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">AUTHORIZATION, DISCLOSURE, PRIVACY STATEMENT (3-in-1)<\/h3>\r\n\r\n\r\n<div id=\"frm_field_1784_container\" class=\"frm_form_field  frm_full frm_html_container form-field\">\n<h4>PRIVACY POLICY<\/h4>\n<p>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.<\/p>\n<p>Your \u201cnonpublic personal information\u201d (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.<\/p>\n<h5><u>Types of Information That We Gather About You:<\/u><\/h5>\n<ul class=\"adp-list-bullets\">\n<li>Spoken or written information on applications and other documents, such as your name, address, social security number, assets, and income;<\/li>\n<li>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<\/li>\n<li>Information we receive from a credit reporting agency, such as your credit history.<\/li>\n<\/ul>\n<h5><u>You May Opt-Out If You Do Not Want Us to Share Your Information:<\/u><\/h5>\n<ul class=\"adp-list-bullets\">\n<li>You may \"opt-out\" to prevent the disclosure of your nonpublic personal information to third parties (such as your creditors).<\/li>\n<li>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.<\/li>\n<li>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.<\/li>\n<\/ul>\n<h5><u>How We Use Your Information:<\/u><\/h5>\n<ul class=\"adp-list-bullets\">\n<li>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.<\/li>\n<li>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).<\/li>\n<li>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.<\/li>\n<\/ul>\n<h5><u>Client Authorization<\/u><\/h5>\n<p>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.<\/p><\/div>\n<div id=\"frm_field_1787_container\" class=\"frm_form_field  frm_first frm_third frm_adp_label frm_html_container form-field\">\n<h5>CLIENT NAME(S):<\/h5>\n<\/div>\n<div id=\"frm_field_1786_container\" class=\"frm_form_field  frm_third frm_adp_label frm_html_container form-field\">\n<h5>CLIENT SIGNATURE(S):<\/h5>\n<\/div>\n<div id=\"frm_field_1785_container\" class=\"frm_form_field  frm_third frm_adp_label frm_html_container form-field\">\n<h5>DATE:<\/h5>\n<\/div>\n<div id=\"frm_field_1788_container\" class=\"frm_form_field form-field  frm_required_field frm_hidden_container frm_first frm_third frm_res_label frm_signature_sibling\">\r\n    <label for=\"field_p41ng\" id=\"field_p41ng_label\" class=\"frm_primary_label\">1<small>st<\/small> Client Name\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_p41ng\" name=\"item_meta[1788]\" value=\"\"  data-sectionid=\"1782\" data-reqmsg=\"1&lt;small&gt;st&lt;\/small&gt; Client Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1789_container\" class=\"frm_form_field form-field  frm_required_field frm_hidden_container frm_third frm_res_label\">\r\n    <label for=\"field_pge36\" id=\"field_pge36_label\" class=\"frm_primary_label\">1<small>st<\/small> Client Signature\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <div class=\"sigPad\" id=\"sigPad1789\" style=\"max-width:400px;\">\n\t<div class=\"sig sigWrapper\" style=\"height:100px;border-color:#cccccc;--bg-color:#ffffff;--active:#008ec2;--inactive:#dddddd;--active-text:#ffffff;--inactive-text:#ffffff;--button-margin:10px;--button-size:16px;--button-padding:8px;--button-side-margin:20px\">\n\t\t\t\t<ul class=\"sigNav\">\n\t\t\t<li class=\"drawIt\"><a href=\"#\" class=\"current\" title=\"Draw It\" aria-label=\"Draw It\"><i class=\"fas fa-pencil-alt\" aria-hidden><\/i><\/a><\/li>\n\t\t\t<li class=\"typeIt\"><a href=\"#\" title=\"Type It\" aria-label=\"Type It\"><i class=\"far fa-keyboard\" aria-hidden><\/i><\/a><\/li>\n\t\t<\/ul>\n\t\t\t\t<div class=\"typed\">\n\t\t\t<input type=\"text\" name=\"item_meta[1789][typed]\" class=\"name\" id=\"field_pge36\" autocomplete=\"off\" value=\"\" \/>\n\t\t<\/div>\n\t\t<canvas class=\"pad\" width=\"396\" height=\"100\"><\/canvas>\n\t\t<div class=\"clearButton\"><a href=\"#clear\">Clear<\/a><\/div>\n\t\t<input type=\"hidden\" name=\"item_meta[1789][output]\" class=\"output\" value=\"\" \/>\n\t<\/div>\n<\/div>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1790_container\" class=\"frm_form_field form-field  frm_required_field frm_hidden_container frm_third frm_res_label frm_signature_sibling\">\r\n    <label for=\"field_odw44\" id=\"field_odw44_label\" class=\"frm_primary_label\">1<small>st<\/small> Client Date\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_odw44\" name=\"item_meta[1790]\" value=\"\"  data-sectionid=\"1782\" maxlength=\"10\" data-reqmsg=\"1&lt;small&gt;st&lt;\/small&gt; Client Date cannot be blank.\" aria-required=\"true\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1792_container\" class=\"frm_form_field form-field  frm_hidden_container frm_first frm_third frm_res_label frm_signature_sibling\">\r\n    <label for=\"field_86hbw\" id=\"field_86hbw_label\" class=\"frm_primary_label\">2<small>nd<\/small> Client Name\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_86hbw\" name=\"item_meta[1792]\" value=\"\"  data-sectionid=\"1782\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1793_container\" class=\"frm_form_field form-field  frm_hidden_container frm_third frm_res_label\">\r\n    <label for=\"field_e8jrd\" id=\"field_e8jrd_label\" class=\"frm_primary_label\">2<small>nd<\/small> Client Signature\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"sigPad\" id=\"sigPad1793\" style=\"max-width:400px;\">\n\t<div class=\"sig sigWrapper\" style=\"height:100px;border-color:#cccccc;--bg-color:#ffffff;--active:#008ec2;--inactive:#dddddd;--active-text:#ffffff;--inactive-text:#ffffff;--button-margin:10px;--button-size:16px;--button-padding:8px;--button-side-margin:20px\">\n\t\t\t\t<ul class=\"sigNav\">\n\t\t\t<li class=\"drawIt\"><a href=\"#\" class=\"current\" title=\"Draw It\" aria-label=\"Draw It\"><i class=\"fas fa-pencil-alt\" aria-hidden><\/i><\/a><\/li>\n\t\t\t<li class=\"typeIt\"><a href=\"#\" title=\"Type It\" aria-label=\"Type It\"><i class=\"far fa-keyboard\" aria-hidden><\/i><\/a><\/li>\n\t\t<\/ul>\n\t\t\t\t<div class=\"typed\">\n\t\t\t<input type=\"text\" name=\"item_meta[1793][typed]\" class=\"name\" id=\"field_e8jrd\" autocomplete=\"off\" value=\"\" \/>\n\t\t<\/div>\n\t\t<canvas class=\"pad\" width=\"396\" height=\"100\"><\/canvas>\n\t\t<div class=\"clearButton\"><a href=\"#clear\">Clear<\/a><\/div>\n\t\t<input type=\"hidden\" name=\"item_meta[1793][output]\" class=\"output\" value=\"\" \/>\n\t<\/div>\n<\/div>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1791_container\" class=\"frm_form_field form-field  frm_hidden_container frm_third frm_res_label frm_signature_sibling\">\r\n    <label for=\"field_78t6i\" id=\"field_78t6i_label\" class=\"frm_primary_label\">2<small>nd<\/small> Client Date\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_78t6i\" name=\"item_meta[1791]\" value=\"\"  data-sectionid=\"1782\" maxlength=\"10\" data-invmsg=\"Text is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_1847_container\" class=\"frm_form_field frm_section_heading form-field  frm12 frm_adp frm_first section-title\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">AUTHORIZATION, DISCLOSURE, PRIVACY STATEMENT (3-in-1)<\/h3>\r\n\r\n\r\n<div id=\"frm_field_1848_container\" class=\"frm_form_field  frm_full frm_html_container form-field\">\n<h4>CLIENT ENGAGEMENT AGREEMENT<\/h4>\n<p>(This agreement is optional and does not impact the rest of the 3-in-1 form)<\/p>\n<p>Today\u2019s 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.<\/p>\n<p>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\u2019 financial habits so that they can reach financial security. Participating in a regimented course of financial counseling services can increase the client\u2019s sense of well-being and safety through knowledge, and promote changing behaviors that will improve their financial circumstance.<\/p>\n<p>If you are interested in improving your financial capabilities, please agree to the following:<\/p>\n<p>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.<\/p>\n<p>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.<\/p>\n<p>I understand that my counselor will review and discuss an updated Action Plan for each session, and I will receive a copy.<\/p><\/div>\n<div id=\"frm_field_1849_container\" class=\"frm_form_field  frm_first frm_third frm_adp_label frm_html_container form-field\">\n<h5>CLIENT NAME(S):<\/h5>\n<\/div>\n<div id=\"frm_field_1850_container\" class=\"frm_form_field  frm_third frm_adp_label frm_html_container form-field\">\n<h5>CLIENT SIGNATURE(S):<\/h5>\n<\/div>\n<div id=\"frm_field_1851_container\" class=\"frm_form_field  frm_third frm_adp_label frm_html_container form-field\">\n<h5>DATE:<\/h5>\n<\/div>\n<div id=\"frm_field_1852_container\" class=\"frm_form_field form-field  frm_required_field frm_hidden_container frm_first frm_third frm_res_label frm_signature_sibling\">\r\n    <label for=\"field_bpajj\" id=\"field_bpajj_label\" class=\"frm_primary_label\">1<small>st<\/small> Client Name\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_bpajj\" name=\"item_meta[1852]\" value=\"\"  data-sectionid=\"1847\" data-reqmsg=\"1&lt;small&gt;st&lt;\/small&gt; Client Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1853_container\" class=\"frm_form_field form-field  frm_required_field frm_hidden_container frm_third frm_res_label\">\r\n    <label for=\"field_ecqv5\" id=\"field_ecqv5_label\" class=\"frm_primary_label\">1<small>st<\/small> Client Signature\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <div class=\"sigPad\" id=\"sigPad1853\" style=\"max-width:400px;\">\n\t<div class=\"sig sigWrapper\" style=\"height:100px;border-color:#cccccc;--bg-color:#ffffff;--active:#008ec2;--inactive:#dddddd;--active-text:#ffffff;--inactive-text:#ffffff;--button-margin:10px;--button-size:16px;--button-padding:8px;--button-side-margin:20px\">\n\t\t\t\t<ul class=\"sigNav\">\n\t\t\t<li class=\"drawIt\"><a href=\"#\" class=\"current\" title=\"Draw It\" aria-label=\"Draw It\"><i class=\"fas fa-pencil-alt\" aria-hidden><\/i><\/a><\/li>\n\t\t\t<li class=\"typeIt\"><a href=\"#\" title=\"Type It\" aria-label=\"Type It\"><i class=\"far fa-keyboard\" aria-hidden><\/i><\/a><\/li>\n\t\t<\/ul>\n\t\t\t\t<div class=\"typed\">\n\t\t\t<input type=\"text\" name=\"item_meta[1853][typed]\" class=\"name\" id=\"field_ecqv5\" autocomplete=\"off\" value=\"\" \/>\n\t\t<\/div>\n\t\t<canvas class=\"pad\" width=\"396\" height=\"100\"><\/canvas>\n\t\t<div class=\"clearButton\"><a href=\"#clear\">Clear<\/a><\/div>\n\t\t<input type=\"hidden\" name=\"item_meta[1853][output]\" class=\"output\" value=\"\" \/>\n\t<\/div>\n<\/div>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1854_container\" class=\"frm_form_field form-field  frm_required_field frm_hidden_container frm_third frm_res_label frm_signature_sibling\">\r\n    <label for=\"field_cwviz\" id=\"field_cwviz_label\" class=\"frm_primary_label\">1<small>st<\/small> Client Date\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_cwviz\" name=\"item_meta[1854]\" value=\"\"  data-sectionid=\"1847\" maxlength=\"10\" data-reqmsg=\"1&lt;small&gt;st&lt;\/small&gt; Client Date cannot be blank.\" aria-required=\"true\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1855_container\" class=\"frm_form_field form-field  frm_hidden_container frm_first frm_third frm_res_label frm_signature_sibling\">\r\n    <label for=\"field_s9m31\" id=\"field_s9m31_label\" class=\"frm_primary_label\">2<small>nd<\/small> Client Name\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_s9m31\" name=\"item_meta[1855]\" value=\"\"  data-sectionid=\"1847\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1856_container\" class=\"frm_form_field form-field  frm_hidden_container frm_third frm_res_label\">\r\n    <label for=\"field_y7ld6\" id=\"field_y7ld6_label\" class=\"frm_primary_label\">2<small>nd<\/small> Client Signature\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"sigPad\" id=\"sigPad1856\" style=\"max-width:400px;\">\n\t<div class=\"sig sigWrapper\" style=\"height:100px;border-color:#cccccc;--bg-color:#ffffff;--active:#008ec2;--inactive:#dddddd;--active-text:#ffffff;--inactive-text:#ffffff;--button-margin:10px;--button-size:16px;--button-padding:8px;--button-side-margin:20px\">\n\t\t\t\t<ul class=\"sigNav\">\n\t\t\t<li class=\"drawIt\"><a href=\"#\" class=\"current\" title=\"Draw It\" aria-label=\"Draw It\"><i class=\"fas fa-pencil-alt\" aria-hidden><\/i><\/a><\/li>\n\t\t\t<li class=\"typeIt\"><a href=\"#\" title=\"Type It\" aria-label=\"Type It\"><i class=\"far fa-keyboard\" aria-hidden><\/i><\/a><\/li>\n\t\t<\/ul>\n\t\t\t\t<div class=\"typed\">\n\t\t\t<input type=\"text\" name=\"item_meta[1856][typed]\" class=\"name\" id=\"field_y7ld6\" autocomplete=\"off\" value=\"\" \/>\n\t\t<\/div>\n\t\t<canvas class=\"pad\" width=\"396\" height=\"100\"><\/canvas>\n\t\t<div class=\"clearButton\"><a href=\"#clear\">Clear<\/a><\/div>\n\t\t<input type=\"hidden\" name=\"item_meta[1856][output]\" class=\"output\" value=\"\" \/>\n\t<\/div>\n<\/div>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1857_container\" class=\"frm_form_field form-field  frm_hidden_container frm_third frm_res_label frm_signature_sibling\">\r\n    <label for=\"field_2d2ns\" id=\"field_2d2ns_label\" class=\"frm_primary_label\">2<small>nd<\/small> Client Date\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_2d2ns\" name=\"item_meta[1857]\" value=\"\"  data-sectionid=\"1847\" maxlength=\"10\" data-invmsg=\"Text is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1859_container\" class=\"frm_form_field  frm12 frm_first frm_html_container form-field\">\n<div class=\"engagement-agreement-bottom\">\n  Please ask your counselor about these other types of counseling that may be available to you at this agency.<\/p>\n<div class=\"row\">\n<div class=\"col-xs-12 col-sm-6\">\n      <span class=\"list-title\"><u>One-on One Counseling<\/u><\/span><\/p>\n<ul>\n<li>Pre-Purchase<\/li>\n<li>Credit & Budget<\/li>\n<li>Post Purchase \u2013 Non-Delinquency (Home maintenance\/Financial Mgt)<\/li>\n<li>Post-Purchase \u2013 Foreclosure Mitigation<\/li>\n<li>Reverse Mortgage\/HECM<\/li>\n<li>Rental Topics<\/li>\n<li>Homeless Assistance<\/li>\n<li>Financial Education Coaching (after the Financial Education Workshop)<\/li>\n<\/ul><\/div>\n<div class=\"col-xs-12 col-sm-6\">\n      <span class=\"list-title\"><u>Workshops<\/u><\/span><\/p>\n<ul>\n<li>Financial Education<\/li>\n<li>Pre-Purchase<\/li>\n<li>Anti-Predatory Lending &<br \/>\n(Home maintenance\/Financial Mgt) Foreclosure Prevention<\/li>\n<li>Fair Housing\/Fair Lending<\/li>\n<\/ul><\/div><\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"frm_field_1860_container\" class=\"frm_form_field frm_section_heading form-field  frm12 frm_adp frm_adp_last frm_first section-title\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">AUTHORIZATION, DISCLOSURE, PRIVACY STATEMENT (3-in-1)<\/h3>\r\n\r\n\r\n<div id=\"frm_field_1861_container\" class=\"frm_form_field  frm_full frm_html_container form-field\">\n<h4><u>COUNSELING AGENCY DISCLOSURES<\/u><\/h4>\n<p><u>Please Initial<\/u><\/div>\n<div id=\"frm_field_1873_container\" class=\"frm_form_field form-field  frm_left_container frm_full frm_initials\">\r\n    <label for=\"field_1ch63\" id=\"field_1ch63_label\" class=\"frm_primary_label\">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.\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_input_group frm_with_box frm_with_post\"><input type=\"text\" id=\"field_1ch63\" name=\"item_meta[1873]\" value=\"\"  data-sectionid=\"1860\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/><span class=\"frm_inline_box\">Initials<\/span><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1874_container\" class=\"frm_form_field form-field  frm_left_container frm_full frm_initials\">\r\n    <label for=\"field_xkver\" id=\"field_xkver_label\" class=\"frm_primary_label\">I have been offered information on alternative services, programs, and products.\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_input_group frm_with_box frm_with_post\"><input type=\"text\" id=\"field_xkver\" name=\"item_meta[1874]\" value=\"\"  data-sectionid=\"1860\" maxlength=\"2\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/><span class=\"frm_inline_box\">Initials<\/span><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1875_container\" class=\"frm_form_field form-field  frm_left_container frm_full frm_initials\">\r\n    <label for=\"field_hm3nf\" id=\"field_hm3nf_label\" class=\"frm_primary_label\">I understand I 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