HOMEOWNERSHIP OC INTAKE FORM

HOMEOWNERSHIP OC

HOOC CLIENT INTAKE
Intake Date:

Month Day Year
Date
Part I: CLIENT INFORMATION
Client First Name
Client Last Name
Client Spouse First Name
Client Spouse Last Name
Client Street Address
Client City
Client State
Client Zip Code
Client Rural Area

Yes No
Client Home Phone
Client Work Phone
Client Cell Phone
Client Email
example@example.com
Best Time To Contact
Preferred Contact Type

Email Home Phone Work Phone Cell Phone
Client Limited English Proficiency:

Yes No
Part II: DEMOGRAPHICS
Client Race ID

Black/African American Native Hawaiian or Pacific Islander Black/African American & White Asian & White American Indian or Alaskan Native & White American Indian Asian White American Indian or Alaskan Native & Black or African American Other
Client Ethnicity

Not Hispanic Hispanic
Age
Date of Birth

Month Day Year
Date
Household Size:
Client Income Level (Annual Household Income)$
Client Household Type:

Single Adult Married with Dependents Female Headed Single Parent Household Male Headed Single Parent Household Married without Dependents 2 or more Unrelated Adults Other
Dependent Relationship/Age
Dependent Relationship/Age
Dependent Relationship/Age
Dependent Relationship/Age
Dependent Relationship/Age
Dependent Relationship/Age
Client Education Grade

Graduate School Junior College University High School/GED Junior High School Elementary Vocational Other
Client Disabled

Yes No
% or Level of Disability
Client Marital Status

Single Married Divorced Separated Widowed
Gender:

Male Female
First Time Homebuyer

Yes No
Total Co-Applicants
County:
Referral Source ( How you heard about us)
Military Service:

No Active Veteran Active Veteran
Foreign Born:

Yes No
Part III: HOUSEHOLD INCOME

Household Income

	Gross Income	Net Income/Month	Income Source (job, SSI, unemployment)	Company Source (employer, etc.)
Client Income
Client Income
Client Spouse Income
Other Income
Total (x12=Total Gross Annual Income $)

Household Expense

	Amount in Dollars
Rent/Mortgage
HOA/Taxes/Insurance
Gas & Electric
Water
Cable
Internet
Food
Cell Phone
Gasoline
Rx
Daycare
Medical Insurance
Car Insurance
Car Payment
Credit Cards
Personal Loans
Student Loans
Child Support
Spousal Support
Other
Other
Other

TOTAL HOUSEHOLD INCOME
TOTAL HOUSEHOLD EXPENSES
714.204.2314 www.HOMEOWNERSHIPOC.ORG
HOMEOWNERSHIP OC

CLIENT INTAKE
Part IV: HOUSEHOLD ASSETS

Household Assets

	Cash/Market Value	Institution(bank, credit union, etc.)	Asset Type(checking, 401K, IRA, etc.)
Client
Client Spouse
Joint
Other
Total

Part V: A. Rental or Owned Property Information
Owner: Original Purchase Date:

Month Day Year
Date
Owner:
Y or N
Original Purchase Price:
Present Market Value:
Rent:
Y or N
Rent Amount
No. Yrs:
Type of Property:
No. Units:
BR:
BA:
Rental issues:
Part VIII: HOME OWNERSHIP/MORTGAGE ISSUES
Check All that apply:

First Time Home Buyer Counseling Requested Mortgage Assistance/Foreclosure Counseling Requested VA Loan Information Requested HECM Counseling Attend Home Buyer Education Program Legal Assistance Counseling Credit Counseling Bankruptcy Counseling Financial Management Counseling Housing Resources Rental Counseling Real Estate Scam Counseling Affordable Housing Counseling Requested Military Financial Readiness Counseling Other
Check All that apply:

Homeless Counseling Requested Other
Part IX: REASONS FOR HOUSING ISSUES
Check all that apply:

Need Housing Information Loss of Income or Reduction of Income Increase in Expenses Want to Buy a Home Increase in Loan Payment Poor Budget Management Medical Issues Divorce/Separation Business Venture Failed Relocation Covid-19 issue Other
Comments:
714.204.2314 www.HOMEOWNERSHIPOC.ORG
HOMEOWNERSHIP OC

COUNSELING AGREEMENT
Dear Client:

Upon completion of your counseling session with your counselor, you are given an Action Plan to aid you in the counseling experience and expectations from HOMEOWNERSHIP OC.

Please understand that there is a high volume of clients who are in similar situations and we are trying our best to meet their needs as our capacity will allow.
I UNDERSTAND THAT:
1. HOMEOWNERSHIP OC’s workshop provides counseling advice through its counselors, educators, and its Partners/Supporters. It is your sole responsibility to seek any future services that may be needed. This file and supporting documents will be retained by HOMEOWNERSHIP OC and information provided might be shared with HOMEOWNERSHIP OC, partners, supporters or 3 parties to provide service to you.

2. HOMEOWNERSHIP OC may receive funding from the US Dept. of HUD and/or HUD Intermediaries and other grantors and as such, is required to: a) share some of my personal information with HUD program administrators or their agents; b) to open my file to be reviewed for purposes of program monitoring, compliance; c) to conduct follow up with me related to program evaluation.

3. HOMEOWNERSHIP OC and its nonprofit partners provide housing counseling after which I will receive a written action plan consisting of recommendation for handling my finances, credit, and possibly including referrals to housing agencies as appropriate.

4. A counselor may answer and provide information, but not give legal advice. If I want legal advice, I will be referred for appropriate assistance.

5. HOMEOWNERSHIP OC and its nonprofit partners provide information and education on numerous loan products and housing programs and I further understand that the housing counseling I receive from HOMEOWNERSHIP OC in no way obligates me to choose any of these particular products or housing programs.

6. I may be referred to other housing services of 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.

7. HOMEOWNERSHIP OC hosts Workshops and events to help me/participating individuals (“Participants”) among other services distinguish legal problems from non-legal problems, and to refer them to service providers, agencies, organizations, or other lawyer sources to provide them with any necessary substantive legal advice or representation. I further understand that by signing and dating this form, HOMEOWNERSHIP OC and its counselors do not and cannot provide legal advice or guidance in the course of the meetings with Participants, and do not establish or create any type of attorney-client relationships with Participants. I also understand that after consultation with counselor, Participants are urged to promptly consult with the service providers, agencies, organizations, or other lawyer referral sources to which the Participants have been referred for follow up on their potential legal issues.

I affix my signature below in agreement of what is stated in this Counseling Agreement.
Client Signature

Clear
Date

Month Day Year
Date
714.204.2314 www.HOMEOWNERSHIPOC.ORG
HOMEOWNERSHIP OC

Client Disclosure Form
HomeOwnership OC is pleased that you have come to us for housing counseling services and we look forward to working with you. We are here to provide you with housing solutions and counseling. However, you may use services other than those provided by this agency. Generally, your services may include the following:
- The gathering of essential demographic and financial information to help us resolve your housin g need
- An assessment of your housing situation
- A case management plan that provides instructions and identifies resources for reso lving your housing need
- Individual face to face, telephone , internet, email and/or group counsel ing designed to guide yo u through the process of resolving housing n eeds.
- Follow - up calls , emails, and/or letters to track the outcome of our services :
- 1) Pre - purchase Counseli ng = Preparing for Home Purchase
- 2) Pre - P urchase Homebuyer Education Wor kshops = Online Workshop
- 3) Fair Housing Pre - Purchase Education Workshops = Group
- 4) Mortgage Delinquency and Default Resolution Counseling Mortgage Assista nce
- 5) Non - Deli nquency Post Purchase Workshops = After purchase counsel in g
- 6) Financial Managemen t/Budget Counseling = Budgeting
- 7 ) Financial, Budgeting and Credit Workshops = Credit Improvement
HOOC upholds the highest standards of customer service. As such, HOOC staff members providing these services will adhere to the following guidelines:
- H OOC d oes not offer legal counsel or services. H OOC staff members will provide counseling, group education and/or instructional information only regarding your housing, personal financial management or credit situation under this program.
- H OOC does not provide debt consolidation services nor will any member of H OOC ’s staff takeover or assume responsibility for the finances of any participating client.
- H OOC does not pay or receive fees or other considerations for referrals to or from any program administered by us.
- H OOC staff members will not recommend that clients participate or engage in any services w hereby the staff members themselves or any member of their immediate family have a financial interest.
- No staff member of H OOC will disc lose any personal inform ation without proper authorization of the participant.
- H OOC strongly believes in and prom otes housing choice. To that end, HOOC does not endorse any realtor or lender and you are free to choos e any realtor or lender of your choice.
- Participants in H OOC ’s Pre - Purchase Counseling/ Home Buyer Education/ Down P ayment Assistance Programs may shop for and select the lender and realtor that best suits their needs.
- H OOC in many instances, will need to pull your credit report in order to ass ess the condition of you r credit either to determine your readiness for ownership or to assist in the resolution of mortgage delinquency. HOOC will p ull your c redit with little to no effect on your credit score.
- H OOC employs persons who are qualified to p rovide the services rend ered. To that end, all H OOC H ousing C ounselors are required to be HUD C ertified. New counselors employed by H OOC have one year to acquire such certification, which can be obtained through the Association of Housing Counselors, th e National Federation of Housing Counselors or Neighbor Works. Central to H OOC ’s mission is the elimination of housing discrimination and education regarding Fair Housing laws . All of H OOC programs and services are required to educate participants abou t t heir rights and responsi bilities under local, state and Feder al Fair Housing laws. Please be advised that you , the client, are not obligated to receive, purchase or utilize any other services offered by HOOC , or its exclusive partners, in order to receive housing counseling servi ces. This certifies that I have read and understood the above statement of disclosure.
Participant Signature

Clear
Date

Month Day Year
Date
Phone / Online Counseling:

Yes No
Participant Signature

Clear
Date

Month Day Year
Date
714.204.2314 www.HOMEOWNERSHIPOC.ORG
HOMEOWNERSHIP OC

HOMEOWNERSHIP OC PRIVACY POLICY
Homeownership OC is a nonprofit housing counseling agency that promotes housing opportunities and homeownership. Our mission is to promote and preserve the dream of home ownership through outreach, education, counseling, and financing. Homeownership OC works to educate the public, especially the low income and under-served populations, on all aspects of owning or renting a home. We are a one stop shop and a free resource here to assist the community with any and all housing related issues. We realize that the concerns you bring to us are highly personal in nature and we are committed to the responsible management, use and protection of personal information. We assure you that all information shared both orally and in writing will be managed within legal and ethical considerations. You “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 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 Gathered

We collect personal information to support our housing counseling program and to aid your housing needs counseling. We collect personal information about you and we may disclose the following kinds of personal information about you:

1. Information we receive from you orally, on applications or forms, such as name, address, social security number, employer, occupation, assts, debts and income;

2. Information about your transactions with us, our affiliates, your creditors. Or others, such as your account balance, payment history, parties to transactions and credit usage; and

3. Information we receive from a consumer credit reporting agency, such as your credit bureau reports, your credit history and your credit worthiness.

You May Opt-Out of Certain Disclosures

1. You have the opportunity to “opt-out”, we will not be able to answer questions from your creditors. If at any time, you wish to change your decision and “opt-out”, you may call us at (800) 954-0441.

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 3rd parties where we have determined that it would be helpful to you, would aid us in counseling you, or is a requirement of grants 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)

Confidentiality and Security

We restrict access to personal information about you to those of our employees, volunteers and affiliated organizations 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. Our safeguards strive to comply with federal regulations to guard your personal information.

714.204.2314 www.HOMEOWNERSHIPOC.ORG
HOMEOWNERSHIP OC

PRIVACY POLICY
Directing Us Not To Make Disclosures to Third Parties

If you prefer that we not disclose personal information about you to unaffiliated third parties, you may opt out of those disclosures, that is, you may direct us not to make those disclosures (other than disclosures permitted by law)

1. If you wish to opt out of disclosures to unaffiliated third parties other than nonprofit organizations involved in community development, you may check the box of the Privacy Choice Form below.

PRIVACY CHOICE FORM

If you want to opt out, that is direct us not to make disclosure about your personal information (other than disclosures permitted by law) as described in this notice, check the box below to indicate your privacy choice:
Limit disclosure of personal information about me to unaffiliated third parties other than nonprofit organizations involved in community development, or as bylaw and other reporting requirements.
PRINT NAME:
SIGNATURE:

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If your current address is the same as the property address please check box, otherwise, please write your current address below

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Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
714.204.2314 www.HOMEOWNERSHIPOC.ORG
Should be Empty:

Part I: CLIENT INFORMATION

Part II: DEMOGRAPHICS

Part III: HOUSEHOLD INCOME

HOMEOWNERSHIP OC

Part IV: HOUSEHOLD ASSETS

Part V: A. Rental or Owned Property Information

Part VIII: HOME OWNERSHIP/MORTGAGE ISSUES

Part IX: REASONS FOR HOUSING ISSUES

HOMEOWNERSHIP OC

I UNDERSTAND THAT:

HOMEOWNERSHIP OC

HOMEOWNERSHIP OC

HOMEOWNERSHIP OC