DATA INTAKE FORM. Address: Fax: Send authorization via: LOAN INFORMATION

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1 DATA INTAKE FORM Date: Call In or Walk In CMAX #: Hud# Start Time: End Time: Borrower: DOB: Age: DOB: Age: Gender: M F Race Hispanic: Y N Gender: M F Race Hispanic: Y N Education level: Military Status: Property Education: Military Status: City: Zip Code: County: Mailing Address (if different from property): Home Phone# Best time to contact you? Cell Phone# Work# Fax: Send authorization via: How did you hear about us? Household Information: Family Size Single Single parent female-head Single parent male-head Married with children Married without children Two or more unrelated adults Other Total Household Income: $ (Annually) Part-time income $ Source(s) of Income: Salary $ Pension $ SSI $ Unemployment $ _ Food Stamps $ Alimony $ SSDI $ TANF $ Child Support $ LOAN INFORMATION Lender: Contact Number: Have you been in contact with your lender? Y N Last Date of Contact? Status of Loan: Current days days days days 181+ days Current Interest Rate? _% Don t know Current Payment? $ Don t Know Purchase Date: Purchase Price: $ Principal Balance Owed? $ Type of Loan: Conventional Interest Only VA/FHA ARM Have you refinanced? Y N Date of Last Refinance: 2 nd Mortgage? Y N Lender: Property Value: $ Contact# 2 nd Mortgage payment: $ 2 nd Mortgage Interest Rate: % Don t Know Status of Loan: Current days days days days 181+ days What brought you to Southside Community Development & Housing Corporation? Late Payments Refinance Loan Reset Reset Date: Loan Modification Other Explain Delinquent Loans: Initial cause of default: How many months are you behind? Ever had a loan modification, trial payment plan, or repayment plan? Y N Date of Last Plan:

2 SOUTHSIDE COMMUNITY DEVELOPMENT & HOUSING CORPORATION AUTHORIZATION & DISCLOSURE Office Use Only Lender 1st Loan # 2nd Loan Counselor Office Phone Fax Borrower: Date of Birth: Social Security #: Phone #: Day: Eve: Cell: Date of Birth: Social Security #: Phone #: Day: Eve: Cell: DISCLOSURE Southside Community Development & Housing Corporation is an organization that provides homeownership counseling to homebuyers and foreclosure prevention counseling for homeowners. Southside Community Development & Housing Corporation assists clients through homeownership counseling and education services. There are many real estate brokers, mortgage lenders and mortgage brokers and you, as a client of Southside Community Development & Housing Corporation, are free to choose whomever you please to provide these types of services to you. AUTHORIZATION FORECLOSURE PREVENTION CLIENTS I/We authorize Southside Community Development & Housing Corporation, its staff or representatives, to act on my/our behalf for the purpose of seeking a resolution with regard to the property listed above. I/We authorize our lending institution/mortgage company to fax, mail, or any items requested by Southside Community Development & Housing Corporation in reference to our mortgage delinquency immediately. I understand that Southside Community Development & Housing Corporation 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 housing agencies as appropriate. I understand that Southside Community Development & Housing Corporation 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 give permission for NFMC program administrators and/or their agents to follow-up with me for the purposes of program evaluation. I acknowledge that I have received a copy of the Southside Community Development & Housing Corporation Privacy Policy. AUTHORIZATION ALL CLIENTS Pursuant to Public Law 91-50B, Title VI, Section 604 (2) & (3) A & B and Section 610 (a) (d), I/We hereby authorize any Credit Reporting Agency to disclose any consumer credit information to Southside Community Development & Housing Corporation and hereby name Southside Community Development & Housing Corporation as the authorized person of my choosing. I/We authorize them to obtain my credit report for the purpose of discussing and/or negotiating all matters regarding pre- and post-purchase counseling. Additionally, you may discuss my file with /Southside Community Development & Housing Corporation personnel (Law No (d) 1). I understand that I 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. 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 Southside Community Development & Housing Corporation provides information and education on numerous loan products and housing programs and I further understand that the housing counseling I receive from Southside Community Development & Housing Corporation in no way obligates me to choose any of these particular loan products or housing programs. I acknowledge that this document also serves as Southside Community Development & Housing Corporation's Privacy Policy. ACKNOWLEDGMENT I/we understand that Southside Community Development & Housing Corporation provides information and education on numerous loan products and housing programs and I further understand that the housing counseling I receive from Southside Community Development & Housing Corporation in no way obligates me to choose any of these particular loan products or housing programs. I/we have read and received a copy of this disclosure form. BORROWER SIGNATURE _ CO-BORROWER SIGNATURE DATE DATE 1624 Hull Street, Richmond, VA Phone:

3 Third Party Authorization Form Mortgage Lender/Servicer Name [Account][Loan] Number The undersigned Borrower and Co-Borrower (if any) (individually and collectively, Borrower or I ), authorize the above mortgage lender/servicer and its successors and assigns (individually and collectively, Servicer ) and the following third parties [Counseling Agency] [State HFA Entity] [Other Third Party] [Agency Contact Name and Phone Number] [State HFA Contact Name and Phone Number] [Third Party Contact Name and Phone Number] [Relationship of Other Third Party to Borrower and Co-Borrower] (individually and collectively, Third Party ) to obtain, share, release, discuss, and otherwise provide to and with each other public and non-public personal information contained in or related to the mortgage loan of the Borrower. This information may include (but is not limited to) the name, address, telephone number, social security number, credit score, credit report, income, government monitoring information, loss mitigation application status, account balances, program eligibility, and payment activity of the Borrower. I also understand and consent to the disclosure of my personal information and the terms of any agreements under the Making Home Affordable or Hardest Hit Fund Programs by Servicer or State HFA to the U.S. Department of the Treasury or their agents in connection with their responsibilities under the Emergency Economic Stabilization Act. The Servicer will take reasonable steps to verify the identity of a Third Party, but has no responsibility or liability to verify the identity of such Third Party. The Servicer also has no responsibility or liability for what a Third Party does with such information. Before signing this Third Party Authorization, beware of foreclosure rescue scams! It is expected that a HUD-approved housing counselor, HFA representative or other authorized third party will work directly with your lender/mortgage servicer. Please visit to verify you are working with a HUD-approved housing counseling agency. Beware of anyone who asks you to pay a fee in exchange for a counseling service or modification of a delinquent loan. This Third-Party Authorization is valid when signed by all borrowers and co-borrowers named on the mortgage and until the Servicer receives a written revocation signed by any borrower or co-borrower. I UNDERSTAND AND AGREE WITH THE TERMS OF THIS THIRD-PARTY AUTHORIZATION: Borrower Co-Borrower Printed Name _ Printed Name Signature SIGN _ Signature SIGN Date _ Date

4 Privacy Policy Southside Community Development & Housing Corporation (SCDHC) 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 the Foreclosure Mitigation 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 that 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 ext 106 and do so. Release of your information to third parties O 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. O 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). O 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. Client s signature_ Client s signature_ Date Date

5 Borrower: Monthly Household Budget Loan #: City: State: Zip Code: A. Household Expenses B. Borrower Monthly Income Fixed Monthly Expenses Current Projected Household Income Gross Net Mortgage Employment Income 2nd Mortgage Disability Gas & Electric Rental Income Heating Oil Unemployment Water & Sewer Child Support/Alimony Telephone Other Car Payment 1 Car Payment 2 Auto Insurance Co-Borrower Monthly Income Life Insurance Household Income Gross Net Medical Insurance Employment Income Alimony/Child Support Disability HOA/Condo Fees Rental Income Property Taxes/Insurance Unemployment Other/Credit Cards $0.00 Child Support/Alimony Sub-Total Fixed Expenses $0.00 $0.00 Other Variable Monthly Expenses Current Projected C. Credit Card & Other Debts Groceries Eating Out Fuel/Gas Bus/Taxi/Parking Car Repair Toiletries/Hair Care Medical Prescriptions Day Care Cable TV Clothing/Laundry Church/Charity Entertainment Cell Phone Other Sub-Total Variable Expenses TOTAL MONTHLY EXPENSES Creditor Name Total Credit Cards D. Surplus/Deficit: Total monthly gross income Total monthly net income Subtract total monthly expenses Monthly surplus or deficit Debt-to-Income Ratios (DTI): Minimum Payment Balance Borrower: Date: Date: Number of cars: Number of people in household: Additional notes: v