NAME of HOUSING COUNSELING AGENCY Intake Form

[NAME OF HOUSING COUNSELING AGENCY]Intake Form

Name: ______

Address: ______

City/State/Zip: ______

County:______Chicago Ward: ______

Primary Phone: ______

Email Address: ______

PLEASE PROVIDE THE FOLLOWING STATISTICAL INFORMATION.

We want to know that we are reaching out to our entire community.

This information is required for Government Reporting.

This information IS NOT shared.

Gender______Date of Birth: ______Marital Status: ______

Race: (Check All That Apply)

African American/Black  Asian Caucasian/White  Latino Native American  Mixed Race

Ethnic Identity:______

In What Country Were You Born? ______

What languages are spoken in your home? ______

Highest level of education completed: ______

Household Income estimate: $______ Weekly Monthly Annual

Number of People in Household: ______Number of Dependents: ______

Female Headed Household?  YES  NO How did you hear about the NHC program?:______

[HOUSING COUNSELING AGENCY NAME] is a [INSERT ORGANIZATION TYPE] organization providing information for educational purposes only. We are not (nor do we represent) realtors, lenders or attorneys. We are certified by the U.S. Department of Housing and Urban Development. All information will be used solely for statistical purposes and will be kept confidential.

______

SignatureDate

[NAME OF HOUSING COUNSELING AGENCY]Intake Form

Name: ______

PLEASE PROVIDE THE FOLLOWING STATISTICAL INFORMATION.

We want to know that we are reaching out to our entire community.

This information is required for Government Reporting.

This information IS NOT shared.

What type of housing do you live in? (Check One)

Unit in a High Rise Building Unit in a Building 4 stories or less Single Family Home or Townhome Homeless

How do you own your home? (Check One)

Own home outright Own homewith a mortgage Rent home with written lease Rent home with oral lease

Living with Family/Friends Living in senior/supportive housing Living in shelter Homeless

How do you pay for your housing? (Check One)

With income from employment With funds from retirement/savings With funds from the government (SSI, UI, etc.)

With Section 8/HCV/VASH/OtherVoucher With funds from another program/person You have no obligation to pay for housing

How much do you pay for housing $______How often do you pay for housing? Weekly Monthly Other

If employed where are you employed?______

If there is another adult employed in your home where do they work? ______

For Pre-Purchase/Homebuyer clients: What type of housing do you want to live in? (Check One)

Unit in a High Rise Building Building 4 stories or less Single Family Home or Townhome

For Foreclosure/Loss Mitigation clients:

Have you missed any mortgage payments? Yes No If Yes how many? ______Have been summoned to appear in court? Yes No

When did you purchase your home?___/___/___What was the purchase price of your home?$______

Who was your original mortgage lender?______

Who is the current lender?______

______

SignatureDate