CREDIT & BUDGET COUNSELING CHECKLIST. Completed Housing Intake Forms Including Budget Sheet, Release of Information, & Privacy Statement

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1 CREDIT & BUDGET COUNSELING CHECKLIST PLEASE BRING EACH OF THE FOLLOWING TO YOUR APPOINTMENT: Completed Housing Intake Forms Including Budget Sheet, Release of Information, & Privacy Statement Copy of Pay Stubs Bring 30 days most recent pay stubs for current employment of anyone working in the household Other Income Documentation Child Support, Pension, Social Security, Disability, Unemployment, Food Stamps, TANF Copy of Most Recent Utility Bill Such as Gas or Electric PLEASE NOTE: Do not bring unopened mail. If you do not have all the items completed and in order at the beginning of your appointment, you may be asked to reschedule for a later date. Foreclosure Checklist REV August 5, 2015

2 HOUSING COUNSELING INTAKE FORM WHO REFERRED YOU (OPTIONAL): Participant s Information LEGAL LAST NAME: FIRST NAME: SOCIAL SECURITY NUMBER: DATE OF BIRTH: AGE: STREET ADDRESS: CITY: ZIP: LIVE IN RURAL AREA? Yes No PHONE: (Home/Cell) (Work) GENDER: M F MARRIED: Yes No SINGLE HEAD OF HOUSE: Yes No # ADULTS IN HOME: # CHILDREN IN HOME: VETERAN: Yes No HANDICAPPED: Yes No ACTIVE MILITARY: Yes No ENGLISH PROFICIENT: Yes No IMMIGRANT/REFUGEE: Yes No COUNTRY OF BIRTH: RACE/ETHNICITY (Check all that apply): African American Hispanic American Indian / Alaskan Native Native Hawaiian or Pacific Islander Asian Other Caucasian EDUCATION: Graduate School High School / GED College Junior High Junior College Primary School Vocational School None Co-Participant s Information LEGAL LAST NAME: FIRST NAME: SOCIAL SECURITY NUMBER: DATE OF BIRTH: AGE: STREET ADDRESS: CITY: ZIP: PHONE: (Home) (Work) (Cell) GENDER: M F MARRIED: Yes No SINGLE HEAD OF HOUSE: Yes No # ADULTS IN HOME: # CHILDREN IN HOME: VETERAN: Yes No HANDICAPPED: Yes No ACTIVE MILITARY: Yes No RACE/ETHNICITY (Check all that apply): African American Hispanic American Indian / Alaskan Native Native Hawaiian or Pacific Islander Asian Other Caucasian Page 1 of 3 Housing Counseling Intake REV August 14, 2015

3 HOUSING COUNSELING INTAKE FORM Employment & Income Information Please list current employment for all persons in your household who are employed. If you work more than one job, list them all. For budgetary purposes it is very important to understand the difference between every other week and bi-monthly pay. If you are unclear of the difference please consult with your counselor. Employer Name (e.g., Target) Employee Title (e.g., Sales Clerk) Start Date (MM/YYYY) Who s Job? Hours Per Week Gross Income (Before Taxes) $ every (circle one) Week, Every Other Week, Twice a Month, Monthly) $ every (circle one) Week, Every Other Week, Twice a Month, Monthly) $ every (circle one) Week, Every Other Week, Twice a Month, Monthly) $ every (circle one) Week, Every Other Week, Twice a Month, Monthly) Does anyone in your house receive any of the following? Check a box for each. Type Yes No Who Receives It? How Much? Child Support or Alimony (circle one) Social Security Unemployment Worker s Compensation Veteran s Benefits Disability Housing Assistance Voucher TANF or Food Stamps (circle one) I / We have $ funds available for down payment, closing cost, and reserves. I / We can save an additional $ per month for my expenses. Page 2 of 3 REV August 14, 2015

4 HOUSING COUNSELING INTAKE FORM What describes your current housing? (Choose One Of The Following): Renter Market Rent Renter Public Housing Renter Subsidized Renter - Section 8 Living with Friends / Family Other Are you a: First Time Homebuyer? Yes No First Generation Homebuyer? Yes No I / We are currently in the process of purchasing a home: Yes No Unknown I / We plan to purchase a home in the next 3 months: Yes No Unknown I / We plan to purchase a home in the next 4-12 months: Yes No Unknown HOUSING COUNSELING AGREEMENT & DISCLOSURE STATEMENT Columbus Housing Partnership, Inc. dba Homeport ( Homeport ) is providing housing counseling for your benefit. Your counselor will provide you with a written plan and budget; assistance in communicating with your loan servicer as necessary; and referrals to community agencies when appropriate. Service Disclosure In the interest of full disclosure, Homeport provides the following programs and services: Housing Counseling Services to include: Credit & Budget Counseling, Post-Purchase Counseling, Foreclosure Prevention Counseling & Reverse Mortgage Counseling Educational Programs to include: Home Buyer Education, Financial Fitness & Home Repair Down Payment Assistance programs Home Sales programs Multi-Family Rental Communities These programs and services are offered regardless of race, color, religion, sex, handicap, familial status, political beliefs, or national origin. These services may also be offered by other providers, and clients are under no obligation to utilize services from Homeport. Participating in any of Homeport s programs or services does not obligate a client to participate in any other service provided by Homeport. If a client receives multiple services at Homeport, his/her information may be shared between programs only to the extent necessary to coordinate the services for which s/he has applied. Funding Disclosure Homeport is funded through a variety of sources to support its mission. The Housing Advisory department s funding sources include the US Department of Housing and Urban Development (HUD), National Foreclosure Mitigation Counseling Program (NFMC), Housing Partnership Network, local and state agencies such as the City of Columbus, Franklin County, Ohio Housing Finance Agency, Office of Community Development and other public and private organizations including United Way of Central Ohio, Huntington, Wells Fargo, KeyBank, Chase, 5/3rd, PNC, Alliance Data and ehome America. Clients are not obligated or expected to receive, purchase, or utilize any other services offered by Homeport or its exclusive funders or partners in order to participate in any of Homeports programs, including housing counseling services. Implementation of any suggestions or information received, participation in programs, or utilization of services provided by or referred by Homeport or their partners are the client s own responsibility and based on decisions made of his/her own free will and choice. The information provided on this form does not constitute an application for mortgage assistance. By signing below, you acknowledge that you have read and understand the above disclosure and that you are not an employee of Homeport or an immediate family member of an employee of Homeport. You also agree to hold harmless Homeport and to be personally responsible for the result of any decisions that you make in connection with services, opportunities and information offered by Homeport, its partners and funders. I acknowledge that I have received a copy of Homeport s privacy policy and practices. PARTICIPANT CO-PARTICIPANT Page 3 of 3 REV August 14, 2015

5 Monthly Budget Worksheet Average Monthly Expenses Home Expenses Amount Per Month Transportation Expenses Amount Per Month First Mortgage Car Payment 1 Second Mortgage Car Payment 2 Homeowner's Insurance (if not included in mrtg.) Taxes (if not included in mrtg.) Auto Insurance Gasoline Electric Gas Water Car Repairs Bus Fare Other Expenses Home Phone Sub-Total: Cell Phone Cable Medical Expenses Amount Per Month Internet Other Expenses Doctor Visits Medication Sub-Total: Dentist Visits Medical Bills Monthly Living Expenses Amount Per Month Sub-Total: Groceries Dining Out Food at Work Other Debts Amount Per Month School lunches Credit Card 1 School Tuition/Fees Credit Card 2 Childcare Credit Card 3 Child Support/Alimony Clothing Church Tithes/Donations Tobacco/Alcohol Life Insurance Medical Insurance Other Expenses Student Loans Debt Mgmt./Bankruptcy IRS Payments Sub-Total: Toiletries Sub-Total: Do not include items deducted from your paycheck. Total of all Expenses:

6 AUTHORIZATION FOR RELEASE OF INFORMATION LOAN NUMBER: Authorization is hereby granted to Homeport to release any applicable information to realtors, lenders, or other agencies or entities necessary for the purpose of assisting in my effort to purchase a home. Authorization is further granted to the realtors, lenders, and other agencies or entities to release all applicable information to Homeport or its representative. Realtors (Please specify) Lenders (Please specify) Other Agencies / Entities (Please specify) Credit Repositories (Please specify) I / We understand that Homeport is hereby authorized to release and receive information pertaining to my case. Participant Co-Participant STREET ADDRESS: STREET ADDRESS: CITY / STATE / ZIP: CITY / STATE / ZIP: SOCIAL SECURITY NUMBER: SOCIAL SECURITY NUMBER: Housing Counseling Intake REV July 31, 2015

7 PRIVACY POLICY AND PRACTICES Homeport is committed to assuring the privacy of individuals and/or families who have contacted us for assistance. We realize that the concerns you bring to us are highly personal in nature, and we assure you that all information shared both orally and in writing will be managed within legal and ethical considerations. What information does Homeport collect? In the course of providing our programs and services to you, we collect information about your personal financial circumstances, called your nonpublic personal information. This information can take any of the following forms: Information we receive from you orally, on applications or other forms, such as your name, address, social security number, assets, and income. Information about your transactions with us, your creditors, or others, such as your account balance, payment history, parties to transactions and credit card usage. Information we receive from a credit reporting agency, such as your credit history. How does Homeport protect my information? Homeport restricts access to your personal information to staff that need to know that information to 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. File level password protection and user authentication and detection software (Windows Server 2003) is enabled to protect your information. Electronic data file storage is in a locked centralized location (server room) and a Cisco ASA 5505 adaptive security device has been deployed for network intrusion protection. How will my information be used by Homeport? Your nonpublic personal information will be released to the following individuals or agencies ONLY UPON YOUR WRITTEN AUTHORIZATION: Financial service providers, such as companies engaged in providing home mortgage loans. Project partners for purposes of program review or monitoring, auditing and oversight purposes only. Homeport receives Congressional funds through the National Foreclosure Mitigation Counseling (NFMC) program, and as such is required to share some of your personal information with NFMC program administrators or their agents for purposes of program monitoring, compliance, and evaluation. Homeport receives funds through the Neighborworks America organization, and as such is required to share some of your personal information with this organization for purposes of monitoring, compliance and evaluation. U.S. Department of Housing and Urban Development (HUD): Homeport is a HUD-certified housing counseling agency and as such is required to share some of your personal information with HUD. HUD follows strict rules to protect your confidentiality. You will not be named in any reports. Although your information may be looked at individually by HUD, or contractors hired by HUD to collect and analyze data, your name will not be associated with any analysis of the data. Only results from groups of people will be reported. Other individuals or agencies, but only when our staff is permitted by law, such as when we are served with a valid subpoena. We may also use anonymous aggregated case file information for the purpose of evaluating our services, gathering valuable research information, reporting to various agencies and/or designing future programs. Page 1 of 2 Housing Counseling Intake REV August 5, 2015

8 PRIVACY POLICY AND PRACTICES What if I don t want Homeport to disclose my nonpublic personal information? You may opt-out of certain disclosures: You have the opportunity to opt-out of disclosures of your nonpublic personal information to third parties (other than disclosures made to project partners and those permitted by law) that is, direct us not to make those disclosures. If you choose to opt-out, we will not be able to answer questions from your creditors. If you choose to opt-out, you may change your decision at any time by calling (614) RELEASE: I hereby authorize Homeport to release nonpublic personal information it obtains about me to (1) my creditors and (2) any third parties necessary to provide me with the services I have requested. I acknowledge that I have read and understand the above privacy practices and disclosures. Participant Co-Participant OPT-OUT: I request that Homeport make no disclosures of my nonpublic personal information to third parties other than project partners and those permitted by law. I understand that by choosing this option Homeport will not be able to answer questions from my creditors. I understand that I may change my decision at any time by calling (614) Participant Co-Participant Page 2 of 2 Housing Counseling Intake REV August 5, 2015