FORECLOSURE PREVENTION COUNSELING INTAKE FORM CLIENT #1

Transcription

1 ML-4909 FORECLOSURE PREVENTION COUNSELING INTAKE FORM CLIENT #1 Name: Address: Mailing address (if different): First Middle Last Street City State Zip Code Street City State Zip Code Home/Cell Phone: ( ) Work Phone: ( ) Primary Language: How did you hear about us? Race (please circle all that apply): White American Indian/Alaskan Native Asian Black or African American Native Hawaiian/Other Pacific Islander Other: Household Size: Are you a veteran? Yes Gender (please circle): Male Female Were you born outside the United States? (please circle): Yes Head of household? Yes Household Type (please circle the most accurate): Single Married w/o children Married w/ children Female Head of Household Male Head of Household Two or more unrelated adults Other: How many dependents (other than those listed by any co-borrower)? What ages are they?,,, Are there non-dependents who will be living in the home? Yes If yes, list below: Relationship Age Relationship Age Hispanic (please circle): Yes Birth Date / / Social Security Number: - - Do you have a disability? Yes Do you have disabled dependants? Yes Education: (please circle one): Below High School Diploma High School Diploma or Equivalent Two-Year College Bachelors Degree Masters Degree Above Masters Degree Marital Status (please circle): 1. Single 2. Married 3. Divorced 4. Separated 5. Widowed Annual Household Income (gross): $ Current Housing Arrangement (please check one): Rent Does not pay rent Homeless Homeowner with mortgage Homeowner with mortgage paid off Are you a First Time Buyer? Yes (you do not currently own a home and have not owned a home in the past 3 years) Page 1 of 5

2 CLIENT #1 EMPLOYMENT Primary Employer: Secondary Employer: CLIENT #2 INFORMATION (other household member) Name: Last First MI Same Address as Client #1? Yes How Long at Address with Client #1? Preferred Contact Type (circle one): Home Phone Cell Phone Work Phone Home: ( ) Work: ( ) ext. Mobile/Cell: ( ) Fax: ( ) Social Security Number: Birth Date: / / Race (please circle one): White Black or African American American Indian/Alaskan Native & White Asian Black/African American & White American Indian/Alaskan Native & Black Asian & White Native Hawaiian/Other Pacific Islander American Indian/Alaskan Native Other: Hispanic: Yes Foreign Born:.. Yes Gender:. Male Female Are you a Veteran:.. Yes Are you disabled?. Yes Education (please circle one): Below High School Diploma Two-Year College Masters Degree High School Diploma or Equivalent Bachelors Degree Above Masters Degree Marital Status (circle one): Single Married Divorced Separated Widowed Relationship to Borrower (circle one): Spouse/Partner Child Sibling Parent Other Relative Relative by Marriage Do you have separate dependants? Yes What ages are they?,,,,,,, Page 2 of 5

3 CLIENT #2 EMPLOYMENT Primary Employer: Secondary Employer: MONTHLY INCOME Client #1 Gross Monthly Income $ Net Monthly Income $ Income: Job 1 - $ Job 2 - $ Job 3 - $ Client #2 Gross Monthly Income(s) $ Net Monthly Income $ Income: Job 1 - $ Job 2 - $ Job 3 - $ OTHER INCOME Alimony/Child Support Social Security Pension Income Public Assistance Dependent SSI Income Disability Income Rental Income CLIENT #1 CLIENT #2 Type Monthly Gross Monthly Gross SAVINGS/INVESTMENTS Check if applicable and the approximate value for each of the following: Type of account Bank/Company Checking account $ Savings account $ Retirement account $ Cash $ LOAN INFORMATION 1 st Mortgage (Primary): Monthly payment: _Amount still owed on loan: _ tice of Default? (circle one) Yes Auction Date: Page 3 of 5

4 Loan TYPE - Please circle all that apply: Insured Conventional FHA USDA Mobile Home Loan Uninsured Conventional VA Assumed Contract for Deed Loan TERM in years (circle one): Are taxes and insurance included in your payment (escrow)?. Yes If not, are your taxes current?... Yes is your insurance current?.... Yes 2 nd Mortgage (Secondary): Monthly payment: _Amount still owed on loan: _ tice of Default? (circle one) Yes Auction Date: Association Dues or 3 rd Mortgage: Monthly payment: _Amount still owed on loan: _ tice of Default? (circle one) Yes Auction Date: DEBTS/EXPENSES TYPE TOTAL OWED MONTHLY PAYMENT Credit card 1 Credit card 2 Credit card 3 Credit card 4 Car 1 Car 2 Student Loan Family Loan Personal Loan Other TOTAL DEBTS/EXPENSES BRIEF DESCRIPTION OF YOUR SITUATION Page 4 of 5

5 Do you want to try to keep your home? Yes Unsure Have you had previous delinquencies? When? Have you had previous workout plans with your mortgage company? When? Have you talked to your mortgage company yet about your current situation? Outcome? AUTHORIZATION, VERIFICATION AND DISCLOSURE: - I understand that I will FULLY PARTICIPATE in the Loan Modification reprocess with my Lender and actively communicating with the Lender s Loss Mitigation Department. - I understand that IF I do not provide ALL requested documents in a timely manner; within 5 business days, the file will NOT be sent to the Lender as they do not accept incomplete packets. - I will NOT receive a follow-up call after my counseling session; unless I call with a question, or I have hit a roadblock with my lender and/or I have attained a loan modification. If WNHS should hear anything from your lender before hand WNHS will give you a call. I understand that when and if I leave a message, I will get a call back within 2 business days. Other concerns will be addressed according to urgency and receipt of message. - I understand that my point of contact will be my foreclosure prevention counselor at WNHS. - I understand that WNHS receives congressional funds through the National Foreclosure Mitigation Counseling (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 understand that the NFMC program administrators and/or their agents may follow-up with me between now and December 31, 2012 for the purposes of program evaluation. - I understand that WNHS provides foreclosure mitigation counseling after which I will receive a written action plan consisting of recommendations for handling my finances, possibly including referrals to other assistance agencies or other WNHS programs/services as appropriate. - I understand that a counselor may answer questions and provide information, but not give legal advice. If I want legal advice, I will be referred for appropriate assistance. - I understand that I may be referred to other services provided by the organization, another agency or agencies as appropriate that may be able to assist with my particular concerns that have been identified. I also understand that I am not obligated to use any of the services offered to me. - I understand WNHS reserves the right to update or change our service delivery model, and will do our best to keep you apprised of these changes. Some or all of the agencies that fund the Foreclosure Program at Willamette Neighborhood Housing Services (WNHS), include, but are not limited to, the Department of Housing and Urban Development (HUD), National Foreclosure Mitigation Counseling (NFMC), Oregon Housing & Community Services (OHCS), and NeighborWorks America. The organizations that fund this program may require WNHS to share my personal information including the information provided above, and all information collected hereafter with program administrators or their agents for purposes of program monitoring, reporting, compliance, and evaluation. WNHS is a community development corporation. WNHS offers many affordable housing products including: affordable rental housing, housing rehabilitation loans, housing development and property sales, housing counseling services, and micro business services. WNHS provides home buyer education, pre-purchase, foreclosure prevention counseling services, as well as mortgage financing. I understand that WNHS encourages me to choose mortgage financing that meets my needs and is in my best interest. I understand that I am under no obligation to utilize any of WNHS services. I further understand I am not obligated to use any services from WNHS partners, and I am free to seek services from other providers. Should you or anyone you are with require special assistance for mobility impairments, visual or hearing impairments or other disabilities, please let the WNHS staff know and arrangements will be made to accommodate those needs. I acknowledge receipt of the WNHS Privacy Policy and understand the privacy options regarding this information. I hereby verify this information to be true and accurate to the best of my knowledge, and if asked can prove accuracy of the information. I identify the person(s) signing the registration form to be the client(s) receiving services from WNHS. Client # 1 Date Client # 2 Date ML-4909 Page 5 of 5