<\/h3>\r\n\r\n\r\n

\r\n

Program\r\n *<\/span>\r\n <\/div>\r\n

\t\t

\t\t CREDIT COUNSELING<\/label><\/div>\n\t\t

\t\t HOMEBUYER CLASS<\/label><\/div>\n\t\t

\t\t CLOSING COST LOAN ASSISTANCE<\/label><\/div>\n\t\t

\t\t MY LIFE - REPAIR PROGRAM<\/label><\/div>\n<\/div>\r\n \r\n \r\n<\/div>\n<\/div>\n

\r\n

APPLICANT<\/h3>\r\n\r\n\r\n

\r\n Full Name\r\n *<\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Email\r\n *<\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Street\r\n *<\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n City\r\n *<\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n State\r\n *<\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Zip Code\r\n *<\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Birth Date\r\n *<\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Phone #\r\n *<\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Social Security #\r\n *<\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n

Citizenship Status\r\n *<\/span>\r\n <\/div>\r\n

\t\t

\t\t Citizen<\/label><\/div>\n\t\t

\t\t Permanent Resident<\/label><\/div>\n\t\t

\t\t Non-Permanent Resident<\/label><\/div>\n<\/div>\r\n \r\n \r\n<\/div>\n

\r\n

Gender\r\n *<\/span>\r\n <\/div>\r\n

\t\t

\t\t Male<\/label><\/div>\n\t\t

\t\t Female<\/label><\/div>\n\t\t

\t\t Other\/Non-Conforming<\/label><\/div>\n<\/div>\r\n \r\n \r\n<\/div>\n

\r\n

First Time Home Buyer\r\n *<\/span>\r\n <\/div>\r\n

\t\t

\t\t Yes<\/label><\/div>\n\t\t

\t\t No<\/label><\/div>\n<\/div>\r\n \r\n \r\n<\/div>\n

\r\n

Handicapped\r\n *<\/span>\r\n <\/div>\r\n

\t\t

\t\t Yes<\/label><\/div>\n\t\t

\t\t No<\/label><\/div>\n<\/div>\r\n \r\n \r\n<\/div>\n

\r\n

Veteran\r\n *<\/span>\r\n <\/div>\r\n

\t\t

\t\t Yes<\/label><\/div>\n\t\t

\t\t No<\/label><\/div>\n<\/div>\r\n \r\n \r\n<\/div>\n

\r\n

Household Type\r\n *<\/span>\r\n <\/div>\r\n

\t\t

\t\t Unmarried<\/label><\/div>\n\t\t

\t\t Married<\/label><\/div>\n\t\t

\t\t Separated<\/label><\/div>\n<\/div>\r\n \r\n \r\n<\/div>\n

\r\n Family Size\r\n *<\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Dependents\r\n *<\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Monthly Income\r\n *<\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Household Income\r\n *<\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Employer Name\r\n *<\/span>\r\n <\/label>\r\n \r\n

If not working enter n\/a<\/div>\r\n \r\n<\/div>\n

\r\n Hourly Rate\r\n *<\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Start Date\r\n *<\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n

Education Level (please check one)\r\n *<\/span>\r\n <\/div>\r\n

\t\t

\t\t Below High School<\/label><\/div>\n\t\t

\t\t High School or Equivalent<\/label><\/div>\n\t\t

\t\t Other<\/label><\/div>\n<\/div>\r\n \r\n \r\n<\/div>\n

\r\n

Ethnicity Hispanic\r\n *<\/span>\r\n <\/div>\r\n

\t\t

\t\t Yes<\/label><\/div>\n\t\t

\t\t No<\/label><\/div>\n<\/div>\r\n \r\n \r\n<\/div>\n

\r\n

Race\r\n *<\/span>\r\n <\/div>\r\n

\t\t

\t\t American Indian or Alaskan Native<\/label><\/div>\n\t\t

\t\t Asian<\/label><\/div>\n\t\t

\t\t White<\/label><\/div>\n\t\t

\t\t Black or African American<\/label><\/div>\n\t\t

\t\t Black or African American & White<\/label><\/div>\n\t\t

\t\t Native Hawaiian or Other Pacific Islander<\/label><\/div>\n\t\t

\t\t Chose Not to Respond<\/label><\/div>\n\t\t

\t\t Other<\/label><\/div>\n<\/div>\r\n \r\n \r\n<\/div>\n

\r\n Enter your race\r\n *<\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n<\/div>\n

\r\n

CO APPLICANT<\/h3>\r\n\r\n\r\n

\r\n Full Name\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Relationship to Applicant\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Email\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Street\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n City\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n State\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Zip Code\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Birth Date\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Phone #\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Social Security #\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n

Citizenship Status\r\n <\/span>\r\n <\/div>\r\n

\t\t

\t\t Citizen<\/label><\/div>\n\t\t

\t\t Permanent Resident<\/label><\/div>\n\t\t

\t\t Non-Permanent Resident<\/label><\/div>\n<\/div>\r\n \r\n \r\n<\/div>\n

\r\n

Gender\r\n <\/span>\r\n <\/div>\r\n

\t\t

\t\t Male<\/label><\/div>\n\t\t

\t\t Female<\/label><\/div>\n\t\t

\t\t Other\/Non-Conforming<\/label><\/div>\n<\/div>\r\n \r\n \r\n<\/div>\n

\r\n

First Time Home Buyer\r\n <\/span>\r\n <\/div>\r\n

\t\t

\t\t Yes<\/label><\/div>\n\t\t

\t\t No<\/label><\/div>\n<\/div>\r\n \r\n \r\n<\/div>\n

\r\n

Handicapped\r\n <\/span>\r\n <\/div>\r\n

\t\t

\t\t Yes<\/label><\/div>\n\t\t

\t\t No<\/label><\/div>\n<\/div>\r\n \r\n \r\n<\/div>\n

\r\n

Veteran\r\n <\/span>\r\n <\/div>\r\n

\t\t

\t\t Yes<\/label><\/div>\n\t\t

\t\t No<\/label><\/div>\n<\/div>\r\n \r\n \r\n<\/div>\n

\r\n

Household Type\r\n <\/span>\r\n <\/div>\r\n

\t\t

\t\t Unmarried<\/label><\/div>\n\t\t

\t\t Married<\/label><\/div>\n\t\t

\t\t Separated<\/label><\/div>\n<\/div>\r\n \r\n \r\n<\/div>\n

\r\n Family Size\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Dependents\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Monthly Income\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Household Income\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Employer Name\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Hourly Rate\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n Start Date\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

\r\n

Education Level (please check one)\r\n <\/span>\r\n <\/div>\r\n

\t\t

\t\t Below High School<\/label><\/div>\n\t\t

\t\t High School or Equivalent<\/label><\/div>\n\t\t

\t\t Other<\/label><\/div>\n<\/div>\r\n \r\n \r\n<\/div>\n

\r\n

Ethnicity Hispanic\r\n <\/span>\r\n <\/div>\r\n

\t\t

\t\t Yes<\/label><\/div>\n\t\t

\t\t No<\/label><\/div>\n<\/div>\r\n \r\n \r\n<\/div>\n

\r\n

Race\r\n <\/span>\r\n <\/div>\r\n

\t\t

\t\t American Indian or Alaskan Native<\/label><\/div>\n\t\t

\t\t Asian<\/label><\/div>\n\t\t

\t\t White<\/label><\/div>\n\t\t

\t\t Black or African American<\/label><\/div>\n\t\t

\t\t Black or African American & White<\/label><\/div>\n\t\t

\t\t Native Hawaiian or Other Pacific Islander<\/label><\/div>\n\t\t

\t\t Chose Not to Respond<\/label><\/div>\n\t\t

\t\t Other<\/label><\/div>\n<\/div>\r\n \r\n \r\n<\/div>\n

\r\n Enter your race\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n<\/div>\n

\r\n

REFERRED TO HOMEOWNERSHIP CENTER BY: (PLEASE CHECK ALL THAT APPLY)<\/h3>\r\n\r\n\r\n

\r\n

Referred By\r\n *<\/span>\r\n <\/div>\r\n

\t\t

Walk in<\/label><\/div>\n\t\t

NHS Website<\/label><\/div>\n\t\t

Facebook<\/label><\/div>\n\t\t

Friend or Family<\/label><\/div>\n\t\t

Lender<\/label><\/div>\n\t\t

Realtor<\/label><\/div>\n\t\t

Other<\/label><\/div>\n<\/div>\r\n \r\n \r\n<\/div>\n

\r\n

Are you currently working with a lender\/bank\r\n *<\/span>\r\n <\/div>\r\n

\t\t

\t\t Yes<\/label><\/div>\n\t\t

\t\t No<\/label><\/div>\n<\/div>\r\n \r\n \r\n<\/div>\n

\r\n Name of Bank\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n<\/div>\n

\r\n

AUTHORIZATION & CERTIFICATION<\/h3>\r\n\r\n\r\n

\n

I Request and Authorize NHS of Greater Berks to:<\/h4>\n

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

Client\u2019s Certification:<\/h4>\n

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

\r\n Applicant Signature\r\n *<\/span>\r\n <\/label>\r\n

\n\t

\n\t\t\t\t

\n\t\t\t
• <\/i><\/a><\/li>\n\t\t\t
• <\/i><\/a><\/li>\n\t\t<\/ul>\n\t\t\t\t
  \n\t\t\t\n\t\t<\/div>\n\t\t<\/canvas>\n\t\t

  Clear<\/a><\/div>\n\t\t\n\t<\/div>\n<\/div>\n\r\n \r\n \r\n<\/div>\n

  \r\n Date\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

  \r\n Co-Applicant Signature\r\n <\/span>\r\n <\/label>\r\n

  \n\t

  \n\t\t\t\t

  \n\t\t\t
  • <\/i><\/a><\/li>\n\t\t\t
  • <\/i><\/a><\/li>\n\t\t<\/ul>\n\t\t\t\t
    \n\t\t\t\n\t\t<\/div>\n\t\t<\/canvas>\n\t\t

    Clear<\/a><\/div>\n\t\t\n\t<\/div>\n<\/div>\n\r\n \r\n \r\n<\/div>\n

    \r\n Date\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n<\/div>\n

    \r\n

    AUTHORIZATION, DISCLOSURE, PRIVACY STATEMENT (3-in-1)<\/h3>\r\n\r\n\r\n

    \n

    MY PERSONAL INFORMATION AND COUNSELING SERVICES<\/h4>\n

    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

    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

    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

    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

    Counseling Services Checklist<\/u><\/h5>\n

    Please initial<\/u> all items that are applicable<\/div>\n

    \r\n I have been verbally advised of the fee schedule, if any, prior to services being provided\r\n <\/span>\r\n <\/label>\r\n

    Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n

    \r\n 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>\r\n <\/label>\r\n

    Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n

    \r\n I have received and reviewed a copy of the Fair Housing Pamphlet\r\n <\/span>\r\n <\/label>\r\n

    Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n

    \r\n I understand that the counselor will discuss my budget with me, and I will receive a copy of my Budget\r\n <\/span>\r\n <\/label>\r\n

    Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n

    \r\n 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>\r\n <\/label>\r\n

    Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n

    \r\n I understand the counselor will explain the next steps needed to reach my financial goal to my satisfaction\r\n <\/span>\r\n <\/label>\r\n

    Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n

    \r\n Homebuyer Counseling\r\n <\/span>\r\n <\/label>\r\n

    Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n

    \r\n Homebuyer Education\r\n <\/span>\r\n <\/label>\r\n

    Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n

    \r\n Homeowner Counseling\r\n <\/span>\r\n <\/label>\r\n

    Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n

    \r\n Homeowner Education\r\n <\/span>\r\n <\/label>\r\n

    Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n

    \r\n Delinquency and Default Counseling\r\n <\/span>\r\n <\/label>\r\n

    Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n

    \r\n Delinquency and Default Education\r\n <\/span>\r\n <\/label>\r\n

    Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n

    \r\n Reverse Mortgage Counseling\r\n <\/span>\r\n <\/label>\r\n

    Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n

    \r\n Fair Housing Education\r\n <\/span>\r\n <\/label>\r\n

    Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n

    \r\n Tenant Counseling\r\n <\/span>\r\n <\/label>\r\n

    Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n

    \r\n Homelessness and Displacement Counseling\r\n <\/span>\r\n <\/label>\r\n

    Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n

    \r\n I want to buy a home in the next six (6) months\r\n <\/span>\r\n <\/label>\r\n

    Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n

    \r\n I want to buy a home, but not in the next six (6) months\r\n <\/span>\r\n <\/label>\r\n

    Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n

    \r\n Other programs, services, or products\r\n <\/span>\r\n <\/label>\r\n

    Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n

    \n

    Counseling Agency Information<\/u><\/h5>\n<\/div>\n

    \r\n Counselor Name\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

    \r\n Phone\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

    \r\n Counseling Agency\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

    \r\n Email\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

    \r\n RX Client Number\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

    \r\n Fax\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n<\/div>\n

    \r\n

    AUTHORIZATION, DISCLOSURE, PRIVACY STATEMENT (3-in-1)<\/h3>\r\n\r\n\r\n

    \n

    PRIVACY POLICY<\/h4>\n

    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

    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

    Types of Information That We Gather About You:<\/u><\/h5>\n

    \n
    • Spoken or written information on applications and other documents, such as your name, address, social security number, assets, and income;<\/li>\n
    • 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
    • Information we receive from a credit reporting agency, such as your credit history.<\/li>\n<\/ul>\n

      You May Opt-Out If You Do Not Want Us to Share Your Information:<\/u><\/h5>\n

      \n
      • You may \"opt-out\" to prevent the disclosure of your nonpublic personal information to third parties (such as your creditors).<\/li>\n
      • 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
      • 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

        How We Use Your Information:<\/u><\/h5>\n

        \n

        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

        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

        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

        Client Authorization<\/u><\/h5>\n

        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

        \n

        CLIENT NAME(S):<\/h5>\n<\/div>\n

        \n

        CLIENT SIGNATURE(S):<\/h5>\n<\/div>\n

        \n

        DATE:<\/h5>\n<\/div>\n

        \r\n

        1st<\/small> Client Name\r\n *<\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

        \r\n

        1st<\/small> Client Signature\r\n *<\/span>\r\n <\/label>\r\n

        \n\t

        \n\t\t\t\t

        \n\t\t\t

        <\/i><\/a><\/li>\n\t\t\t

        <\/i><\/a><\/li>\n\t\t<\/ul>\n\t\t\t\t<\/canvas>\n\t\t

        \n\t\t\t\n\t\t<\/div>\n\t\t

        \r\n

        \r\n

        \r\n

        \n\t

        \n\t\t\t\t

        \n\t\t\t

        <\/i><\/a><\/li>\n\t\t<\/ul>\n\t\t\t\t<\/canvas>\n\t\t

        \n\t\t\t\n\t\t<\/div>\n\t\t

        \r\n

        \r\n

        AUTHORIZATION, DISCLOSURE, PRIVACY STATEMENT (3-in-1)<\/h3>\r\n\r\n\r\n

        \n

        CLIENT ENGAGEMENT AGREEMENT<\/h4>\n

        \n

        CLIENT NAME(S):<\/h5>\n<\/div>\n

        \n

        Clear<\/a><\/div>\n\t\t\n\t<\/div>\n<\/div>\n\r\n \r\n \r\n<\/div>\n2nd<\/small> Client Date\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n<\/div>\n

        (This agreement is optional and does not impact the rest of the 3-in-1 form)<\/p>\n

        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

        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

        If you are interested in improving your financial capabilities, please agree to the following:<\/p>\n

        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

        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

        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

        CLIENT SIGNATURE(S):<\/h5>\n<\/div>\n

        \n

        DATE:<\/h5>\n<\/div>\n

        \r\n

        1st<\/small> Client Name\r\n *<\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

        \r\n

        1st<\/small> Client Signature\r\n *<\/span>\r\n <\/label>\r\n

        \n\t

        \n\t\t\t\t

        \n\t\t\t

        <\/i><\/a><\/li>\n\t\t\t

        <\/i><\/a><\/li>\n\t\t<\/ul>\n\t\t\t\t<\/canvas>\n\t\t

        \n\t\t\t\n\t\t<\/div>\n\t\t

        \r\n

        \r\n

        \r\n

        \n\t

        \n\t\t\t\t

        \n\t\t\t

        <\/i><\/a><\/li>\n\t\t<\/ul>\n\t\t\t\t<\/canvas>\n\t\t

        \n\t\t\t\n\t\t<\/div>\n\t\t

        Clear<\/a><\/div>\n\t\t\n\t<\/div>\n<\/div>\n\r\n \r\n \r\n<\/div>\n

        \r\n

        2nd<\/small> Client Date\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n

        \n

        \n Please ask your counselor about these other types of counseling that may be available to you at this agency.<\/p>\n

        \n

        \n

        One-on One Counseling<\/u><\/span><\/p>\n

        \n

        Pre-Purchase<\/li>\n

        Credit & Budget<\/li>\n

        Post Purchase \u2013 Non-Delinquency (Home maintenance\/Financial Mgt)<\/li>\n

        Post-Purchase \u2013 Foreclosure Mitigation<\/li>\n

        Reverse Mortgage\/HECM<\/li>\n

        Rental Topics<\/li>\n

        Homeless Assistance<\/li>\n

        Financial Education Coaching (after the Financial Education Workshop)<\/li>\n<\/ul><\/div>\n

        \n

        Workshops<\/u><\/span><\/p>\n

        \n

        Financial Education<\/li>\n

        Pre-Purchase<\/li>\n

        Anti-Predatory Lending &\n(Home maintenance\/Financial Mgt) Foreclosure Prevention<\/li>\n

        
        

        Fair Housing\/Fair Lending<\/li>\n<\/ul><\/div><\/div>\n<\/div>\n<\/div>\n<\/div>\n

        \r\n

        AUTHORIZATION, DISCLOSURE, PRIVACY STATEMENT (3-in-1)<\/h3>\r\n\r\n\r\n

        \n

        COUNSELING AGENCY DISCLOSURES<\/u><\/h4>\n

        Please Initial<\/u><\/div>\n

        \r\n 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>\r\n <\/label>\r\n

        Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n

        \r\n

        I have been offered information on alternative services, programs, and products.\r\n <\/span>\r\n <\/label>\r\n

        Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n

        \r\n

        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>\r\n <\/label>\r\n

        Initials<\/span><\/div>\r\n \r\n \r\n<\/div>\n<\/div>\n\t\n\t

        \r\n\r\n

        Submit<\/button>\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n<\/form>\n<\/div>\n

        Clear<\/a><\/div>\n\t\t\n\t<\/div>\n<\/div>\n\r\n \r\n \r\n<\/div>\n1st<\/small> Client Date\r\n *<\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n2nd<\/small> Client Name\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n2nd<\/small> Client Signature\r\n <\/span>\r\n <\/label>\r\n <\/i><\/a><\/li>\n\t\t\t

        Clear<\/a><\/div>\n\t\t\n\t<\/div>\n<\/div>\n\r\n \r\n \r\n<\/div>\n1st<\/small> Client Date\r\n *<\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n2nd<\/small> Client Name\r\n <\/span>\r\n <\/label>\r\n \r\n \r\n \r\n<\/div>\n2nd<\/small> Client Signature\r\n <\/span>\r\n <\/label>\r\n <\/i><\/a><\/li>\n\t\t\t