INTAKE FORM. Signature. Signature. Date. Property Address: City: State: CA Zip Code:

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1 2560 W Shaw Lane #101 Fresno CA Ph Fax INTAKE FORM HUD Approved Agency #84811 Date Property Address: City: State: CA Zip Code: County: Home Phone: Do you currently occupy this home: Yes No Year home was purchased: What would you like to do: Keep this house Sell this house Not Sure Name of person on the loan (Borrower) Name of person on the loan (Co-Borrower) Date of Birth Date of Birth Cell phone number Cell phone number address address Gender: Female Male Marital Status: Single Married Divorced Separated Widowed Other: Race: American Indian/Native Alaskan Asian Black or African American White Native Hawaiian/Pacific Islander Other Gender: Female Male Marital Status: Single Married Divorced Separated Widowed Other: Race: American Indian/Native Alaskan Asian Black or African American White Native Hawaiian/Pacific Islander Other Ethnicity: Hispanic Non-Hispanic Ethnicity: Hispanic Non-Hispanic In Military: Yes No In Military: Yes No Have you filed for bankruptcy? Yes No If yes, when: Are you employed? Employer name: Start date of employment: Are you Self-Employed? Length of time Self-Employed Are you receiving Unemployment? Start date of unemployment Other source of income: Highest Level of Education: Have you filed for bankruptcy? Yes No If yes, when: Are you employed? Employer name: Start date of employment: Are you Self-Employed? Length of time Self-Employed Are you receiving Unemployment? Start date of unemployment Other source of income: Highest Level of Education: Signature Signature Number of minor children in household Total number in household

2 Regarding Subject Property: Name of current Lender: Loan Number: Current Loan Balance $ Current Monthly Payment: $ Interest Rate: % Does your monthly payment include: Taxes Insurance PMI HOA $ No impounds If not escrowed: Annual Insurance premium $ Annual Taxes $ Type of Mortgage: Fixed Adjustable ( 1 yr 2 yr 3 yr 5 yr) Interest Only Hybrid Arm Option ARM Type of Loan: VA Loan FHA Loan Conventional (RHS) USDA Other *Since you have purchased your home, have you ever refinanced? If yes, date: *Have you ever received a loan modification? If yes, date: *Do you have a 2 nd Loan? Yes No Loan Status? Current Delinquent: If delinquent, number of months: Has a Notice of Default been filed? Yes No If yes, date filed/recorded: Has a Notice of Trustee Sale been filed? Yes No If yes, sale date: IDENTIFYING POSSIBLE LOAN SCAMS 1. Did anyone offer to help modify your mortgage, either directly, through advertising, Yes No or by any other means such as a flyer? 2. Were you guaranteed a loan modification or asked to do any of the following: Pay a fee, Yes No Sign a contract, Redirect mortgage payment, Sign over title to your property, or Stop making loan payments? QUESTIONNAIRE How did you hear about the Community Housing Council? Referred by Lender HUD Website Attorney Referred by HUD CHC Website Realtor Friend / Relative Letter from County Other

3 Monthly Budget Monthly Household Income Monthly Household Expenses / Debt Monthly Gross wages First Mortgage (PITI) Auto Payments Overtime 2 nd mortgage / HELOC Auto Insurance Self-Employment Income Unemployment Income Homeowner s Insurance Property Taxes Gas / Oil Medical Insurance (if not deducted from pay) Social Security HOA / Condo fee Prescription / Co-pays Disability Electric, water & sewer Donations / Charity Retirement / Pension Child Support / Alimony Home Phone / Cell Phone Child care Credit cards (total min. payments) Mortgage on other properties Rental Income Tuition Other: Other Groceries Other: TOTAL GROSS TOTAL EXPENSES Borrower Signature: Co-Borrower Signature: COUNSELING ACTION PLAN Currently, my biggest housing need is: Housing Goal: Barriers / Obstacles to reaching my goal: Reduction of Income/ Pay Increase in loan payment Medical Issues / Disability Unemployment Death of Family Member Other: Divorce / Separation Business Failure Other: Increase in expenses Excessive Obligations Other: Action you have already taken to improve your situation? While my housing counselor is: Reviewing my application, documents, and household budget, Informing my lender that I/we are working with the Community Housing Council in order to help rectify my/our situation, Pulling my credit report, verifying other information, and developing recommendations to improve my budget, And assessing what workout options and/or program I/we might quality for, including FHA options. I will: (check all that apply to you) Submit any outstanding documents to my counselor Find a roommate Contact my creditors to lower my liabilities Look for ways to reduce my expenses Contact my lender to inform them of my situation Other: Look for employment Other: Other client / counselor action steps: Borrower Signature: Co-Borrower Signature:

4 FORECLOSURE MITIGATION COUNSELING AGREEMENT As required by 24 CFR (g) I/We, understand that the Community Housing Council (CHC) provides foreclosure mitigation counseling, part of which I will receive a written action plan consisting of recommendations for handling my finances, possibly including referrals to other housing agencies as appropriate. I understand that I am not obligated to use any of the services offered to me. I understand that the CHC receives Congressional funds through the NFMC program and, as such, is required to share some of my personal information with NFMC program administrators or their agents for purposes of program monitoring, compliance and evaluation. I give permission for NFMC program administrators, and/or their agents to follow-up with me within the next three years for the purposes of program evaluation. The counselor will provide information and answer questions, but will not give any sort of tax or legal advice. If I want legal advice, I will be referred for appropriate assistance. It is the responsibility of the counselor to act quickly, provide accurate and useful advice, and to serve your interest. The counselor may be referred to other housing services of the organization or another agency or agencies as appropriate that may be able to assist with particular concerns that have been identified. I understand that I am not obligated to use any of the services offered to me. It is my responsibility to provide accurate information and follow through on action I agree upon. Such actions may include providing/returning documents in a timely manner, showing up to appointment on time, and canceling/rescheduling appointments at least 24 hours in advance. Providing false, misleading, or withholding information may result in the termination of services. I also understand that CHC does not provide direct money to bring my mortgage current, nor do they have control over my lenders decisions or recommendations. I/we certify that we have read and understand the Foreclosure Mitigation Counseling agreement. I/we acknowledge that I/we have received a copy of CHC s list of members and this agreement. Borrower Signature Date Co-Borrower Signature Date CREDIT REPORT AUTHORIZATION AND PRIVACY DISCLOSURE FORM (To Be Completed Prior to Running Credit Reports by Authorized Counselors Only) I hereby authorize and instruct the Community Housing Council (hereinafter CHC) to obtain and review my credit report. My credit report will be obtained from a credit reporting agency chosen by CHC. I understand and agree that CHC intends to use the credit report for the purpose of evaluating my financial readiness to purchase a home and/or to engage in postpurchase counseling activities. My signature below also authorizes the release to credit reporting agencies my financial information or other information that I have supplied to CHC in connection with such evaluation. Authorization is further granted to the credit reporting agency to use a copy of this form to obtain any information the credit reporting agency deems necessary to complete my credit report. In addition, in connection with determining my ability to obtain a loan or to be provided post-purchase counseling, I hereby authorize do not authorize CHC to share with potential mortgage lenders and/or counseling agencies my credit report and any information that I have provided, including any computations and assessments that have been produced based upon such information. These lenders may contact me to discuss loans for which I may be eligible, and these counseling agencies may contact me to discuss counseling services. I/We will provide CHC with VALID identification (CA driver license/id, immigration card) and Social Security Cards, in our names, for either work or other than work purposes. Otherwise, I/We understand that CHC will not be able to assist us with our loan modification. I understand that I may revoke my consent to these disclosures by notifying CHC in writing. Borrower Signature Social Security Number Date of Birth Date Co-Borrower Signature Social Security Number Date of Birth Date

5 2560 W Shaw Lane #101 Fresno CA Ph Fax PRIVACY POLICY The Community Housing Council of Fresno values your trust and is committed to the responsible management and oversight over the collection of personal information. We only collect and use personal information in order to best assists you with the service(s) you ve requested. Information we collect: Information we receive from you orally, on applications or other forms Information about your transactions with us, your creditors, or others Information we receive from a credit reporting agency, and Information we receive from personal and employment references. Information We Disclose: Information we received from you on applications or other forms, such as your name, address, social security number, employer, occupation, assets, debts and income. Information about your transactions with us, our affiliates or others, such as your account balance, payment history and parties to your transactions; and Information we received from a consumer reporting agency, such as your credit bureau reports, your credit history, and your credit worthiness. To Whom We Disclose: We may disclose your personal information to the following types of unaffiliated third parties: Financial service providers, such as companies engaged in providing home mortgage and home equity loans; Others, such as nonprofit organizations involved in community development, but only for program review, auditing, research, and oversight purposes. That reporting data is summarized in aggregate and not identified by individual household. We may also disclose personal information about you to third parties as permitted by law. Confidentiality & Security We restrict access to personal information about you to those of our employees who need to know that information or provide products and services to you. We maintain physical and electronic security procedures to safeguard the confidentiality and integrity of personal information in our possession and to guard against unauthorized access. We use locked files, user authentication and detection software to protect your information. Our safeguards comply with federal regulations to guard your personal information. CONFLICT OF INTEREST As a HUD approved housing counseling agency, CHC is required to fully disclose all actual and potential conflicts of interest. CHC is not a legal firm and do not offer legal advice. Your legal rights regarding a delinquent status of your loan or bankruptcy considerations should be discussed with an attorney. Tax consequences of foreclosure or preforeclosure sales should be discussed with a qualified tax professional. Should you decide to sell your home as a way of avoiding foreclosure, you have a right to choose your own real estate agent, lending institution, and all other real estate industry professionals. Taking in our group or individual counseling services does not require you to use any of our real estate or mortgage services, or use the services of anyone that we may refer to you. CHC provides counseling services in first time home buyer education and counseling, delinquency and default education and counseling, financial management and budgeting education and counseling, and post-purchased education and counseling. Services may be offered by CHC, its subsidiaries, affiliates or directors, officers, employees, agents, or partners may also be offered by other providers and you are under no obligation to utilize services form CHC. CHC s financial affiliations include Rural Community Assistance Corporation (RCAC), Wells Fargo, Chase, Citibank, and Fannie Mae, who are industry partners. Client Initials: Client Initials:

6 2560 W Shaw Lane #101 Fresno CA Ph Fax CHC is a Non-Profit HUD Approved Counseling Agency (HUD HCS # 84811) Third Party Authorization Borrower s Name: Social Security Number: Co-Borrower s Name: Social Security Number: Property Address: City: State: Zip Code: Phone Number: Lender s Name: Loan Number: I hereby authorize Community Housing Council of Fresno, or its Associates, and to communicate, receive and convey information for the above loan number and property address. PASSCODE to facilitate this process on the home owner s behalf is: You can contact: Counselor s Name: Phone Number: / / Borrower s Signature Date / / Co-Borrower s Signature Date Revised 02/28/2014

7 DODD-FRANK CERTIFICATION FORM Dodd-Frank Certification The following information is requested by the federal government in accordance with the Dodd-Frank Wall Street Reform and Consumer Protection Act (Pub. L ). You are required to furnish this information. The law provides that no person shall be eligible to receive assistance from the Making Home Affordable Program, authorized under the Emergency Economic Stabilization Act of 2008 (12 U. S. C et seq.), or any mortgage assistance program authorized or funded by that Act, if such person, in connection with a mortgage or real estate transaction, has been convicted, within the last 10 years, of any one of the following: (A) felony, larceny, theft, fraud or forgery, (B) money laundering or (C) tax evasion. I/we certify under penalty of perjury that I/we have not been convicted within the last 10 years of any one of the following in connection with a mortgage or real estate transaction: a) Felony, larceny, theft, fraud, or forgery, b) Money laundering or c) Tax evasion. I/we understand that the Servicer, the U. S. Department of the Treasury, or their agents may investigate the accuracy of my statements by performing routine background checks, including automated searches of federal, state and county databases, to confirm that I/we have not been convicted of such crimes. I/we also understand that knowingly submitting false information may violate Federal law. This Certificate is effective on the earlier of the date listed below or the date received by your servicer. Borrower Signature Social Security Number Date of Birth Date Borrower Signature Social Security Number Date of Birth Date

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