INTAKE FORM FORECLOSURE / PREDATORY LENDING COUNSELING

Transcription

1 DATE: I. CLIENT INFORMATION INTAKE FORM FORECLOSURE / PREDATORY LENDING COUNSELING Borrower Name: How did you hear about us? Website Have you contacted another agency? Yes No Agency Name Social Security Number: Date of Birth: Head of Household? Yes No Marital Status: Single Married Divorced Separated Race & Ethnicity Language Preference: Address: City, State, Zip: Phone: ( ) - ( ) - Are you disabled? Yes No (Additional services may be available) Farm Worker Yes No Member of a Native American Tribe Yes No Highest Education Level No High School Diploma High School Diploma GED Diploma Vocational Certificate Some College Associates Degree Bachelors Degree Masters Degree Co-Borrower Name: Social Security Number: Date of Birth: Race & Ethnicity Briefly describe the reason for your visit. II. INFORMATION ABOUT HOME Owner Occupant? Yes [ ] No [ ] Address of Property If Different from Above: City, State, Zip Code: Names of all Co-Owners Year Purchased Original Purchase Price Estimated Current Value $ $ Type of Home? 1 family [ ] 2 fam [ ] 3+ fam [ ] Condo [ ] other [ ] Rent received

2 III. MORTGAGE INFORMATION Information on 1 st Mortgage Type of Mortgage Purchase Money Refinance Date Acquired / Cash Out? Yes / No Type of Mortgage Loan Current Balance $ Current Lender or Servicer Loan Account Number Interest Rate % 30 yr. Fixed 15 yr. Fixed Option ARM Interest Only Other When does interest rate adjust? Investor/Insurer, if any FHA VA PMI Fannie Mae Freddie Mac Other Total Monthly Payment $ Taxes and Insurance included? HOA Fees Yes No Annual Tax $ Annual Insurance $ Number of Months Behind Total arrears including costs $ 2 nd MORTGAGES / LIENS Type of Mortgage Purchase Money Refinance Home Equity Loan Debt Consolidation Other Type of Mortgage Loan 30 yr. Fixed 15 yr. Fixed Option ARM Interest Only Adjustable Rate Mortgage Other Current Balance $ Current Lender or Servicer Loan Account Number Total Monthly Payment $ Number of Months Behind

3 IV. HOUSEHOLD FINANCIAL INFO Applicant Employer/Company: Address: Occupation/Title: How Long Employed: Co-Applicant Employer/Company: Address: Occupation/Title: How Long Employed: What is the current Household Income $ wk. mo. yr. Is this Gross [ ] or Take Home [ ]? What are the source(s) of income? How many in the household? Ages: Program Privacy Policy, Disclosure, Authorization, and Conflict of Interest Statement HLCC receives funding and support from entities listed below through contracts and donations. You are not obligated to receive, purchase or utilize any other services offered by our organization or its exclusive partners, in order to receive housing counseling services. We offer the following services: pre-purchase education and counseling, post-purchase education and counseling, and foreclosure prevention education and counseling. Chase Home Mortgage City of Lincoln City of Rocklin City of Roseville City of West Sacramento Citi Mortgage Ocwen PacificWest Companies Prudential Real Estate Union Capitol Loans US Bank Wells Fargo Bank

4 Program Privacy Policy, Disclosure, Authorization, and Conflict of Interest Statement (cont.) The Sacramento Home Loan Counseling Center 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. We assure you that all information shared both orally and in writing will be managed within legal and ethical considerations. Your nonpublic personal information, such as your total debt information, income, living expenses and personal information concerning your financial circumstances, will be provided to creditors, program monitors, and others only with your authorization and signature on this Counseling Agreement. We may also use anonymous aggregated case file information for the purpose of evaluating our services, gathering valuable research information and designing future programs. Types of information we gather about you: 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; and information we receive from a credit reporting agency, such as your credit history. You may opt-out of certain disclosures 1. You have the opportunity to opt-out of disclosures of your nonpublic personal information to third parties (such as your creditors), that is, direct us not to make those disclosures. 2. If you choose to opt-out, we will not be able to answer questions from your creditors. If at any time, you wish to change your decision with regard to your opt-out, you may call us at (916) and do so. Release of your information to third parties 1. So long as you have not opted-out, we may disclose some or all of the information that we collect, as described above, to your creditors or third parties where we have determined that it would be helpful to you, would aid us in counseling you, or is a requirement of grant awards which make our services possible. 2. We may also disclose any nonpublic personal information about you or former customers to anyone as permitted by law (e.g., if we are compelled by legal process). 3. Within the organization, we restrict access to nonpublic personal information about you to those employees who need to know that information to provide services to you. We maintain physical, electronic and procedural safeguards that comply with federal regulations to guard your nonpublic personal information. I/we understand that the Sacramento Home Loan Counseling Center (HLCC) provides foreclosure mitigation counseling after which I/we will receive a written action plan consisting of recommendations for handling my finances, possibly including referrals to other housing agencies as appropriate. I/we also understand that my counselor may answer questions and provide information to me but not give legal advice. If I/we want legal advice, I/we will be referred for appropriate assistance. I/we understand that HLCC 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/we 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. I/we acknowledge that I have received a copy of HLCC s Privacy Policy.

5 I hereby authorize Sacramento Home Loan Counseling Center to release/exchange information from my records in order to assist me in resolving mortgage default. This information will be released only to those institutions, companies and agencies that our organization believes can provide assistance in resolving a mortgage default. Examples of such entities include mortgage Servicers, mortgage investors, public agencies and other nonprofit organizations. If necessary, information on file at another entity may also be released to us. This information release/exchange will be restricted to specific financial data, such as income, budget, debt and mortgage details provided by you. I further authorize HLCC to obtain a consumer credit report on my behalf and verify any additional credit information that may be needed in conjunction with my participating in this Housing Counseling Program. I understand that the provision of services at this organization is not contingent upon my decision concerning the release/exchange of information. The doctrine of informed consent has been explained to me, and I understand the contents to be released/exchanged, the need for the information, and that there are statutes and regulations protecting the confidentiality of authorized information. I hereby acknowledge that this consent is voluntary and is valid until such request is fulfilled. I further acknowledge that I may revoke this consent at any time except to the extent that action based on this consent has been taken. This consent shall expire one (1) year from the date shown below. I also acknowledge that a copy of this form is as valid as the original. Borrower (printed) Borrower (signature) Date Borrower (printed) Borrower (signature) Date Loan Number: Last 4 Digits of SSN: Address: Sacramento Home Loan Counseling Center 1800 Tribute Road, Suite 150, Sacramento, CA Phone (916) Fax (916)