• Client Form:

    Please complete this web intake in its entirety. If you have any questions or are in need of assistance, please contact the office at 518-293-5045.
  • What kind of assistance are you looking for?*

  • About You:

    Please provide some details about you and how to best reach you.
  • Date of Birth:*
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  • Gender*

  • Gender:

  • Are you disabled?*
  • Are you a veteran?*
  • Are you a first time homebuyer?*

  • Education Level:*

  • Marital Status*

  • Do you have a co-applicant?*
  • Co-Applicant Date of Birth:*
     / /
  • Co-Applicant Gender*

  • Gender:*

  • Are they disabled?*
  • Are they a veteran?*
  • Education Level:*

  • Marital Status*

  • How did you hear about us?

  • Contact

    How can we best contact you?
  • Is mailing address the same as property address?
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  • Preferred Method of Contact:*

  • Do you give Friends of the North Country, Inc. permission to leave detailed messages on your voicemail or email?*

  • Are you working with any other community organizations?

  • Your household:

    Please provide details about your household size, demographics, and income. Don't forget to include yourself when counting household members!!
  • Was the crime violent?
  • Does anyone in your household receive Medicaid (income based) or Medicare (65+)?
  • Do you have child care expenses?
  • Does anyone in your household have significant (not reimbursed or covered by insurance) medical expenses?
  • Is anyone in your household a full time student? (If yes, select all that apply)
  • Rows

  • *Gross income is what the income is before any deductions (like taxes, health insurance, retirement, etc.)
    *Net income is what the income is after all deductions (also referred to as "take home" - this is the amount you receive in your bank account or via check.)

  • Property Information:

    Some details about where you live.

  • More Information:

    Some details about your living situation and needs.
  • Are you:
  • What type of education or assistance are you looking for?*

  • Where do you currently live?*

  • Have you utilized any of these resources yet?
  • Do you own your home?*
  • What kind of ownership?*

  • Is your home a stick-built, or a manufactured home?*
  • Do you have a mortgage?*
  • Do you have homeowner's insurance?*
  • Have you received housing assistance in the past?*

  • Septic/sewer*

  • Well/water*

  • Is your roof leaking?*

  • Are you looking for home repair, or do you need help adapting your home for yourself or another disabled household member? (Select all that apply)*

  • Housing Barriers: which of the following need to be repaired/replaced? (Check all that apply)*

  • Housing Barriers: what adaptations would allow you or your family member to comfortably and safely remain in the home? (Check all that apply)*

  • Do you have a signed lease agreement?*
  • Are you behind on your rent?*
  • What's included in the rent, if anything?

  • Do you have renter's insurance?*
  •  -
  • Pets?*

  • When do you hope to buy?*
  • Do you know your credit score?*
  • Do you have any money saved for closings costs/down payment?*
  • Any debts in collections?*
  • Do you have any current loans/debts?*
  • Do you have a mortgage?*
  • Are you:*

  • Select what is included in your mortgage payment:*

  • Do you have a second mortgage?*
  • Select what is included in your second mortgage payment:*

  • Have you had any contact with your mortgage company?*

  • Have you had any contact with the county or town?*

  • Have you been behind on your mortgage before?*
  • Have you been behind on your taxes before?*
  • Have you ever filed for bankruptcy before?*
  • Have you had any notices from an attorney or the court?*
  • Do you have mediation scheduled?*
  • Foreclosure sale scheduled?*
  • Have you already been in contact with a lender about obtaining a reverse mortgage/HECM?*

  • Do you have any unpaid federal debt?*

  • Do you have any special needs?
  • Power of attorney or guardianship?

  • Telephone or face-to-face counseling preferred?*

  • If there is someone you'd like us to contact on your behalf if we are unable to reach you, please leave their contact information below:

  • Budget

    If you are interested in having a counselor help you with any of the above affordable housing needs, please complete the budget below. For annual expenses, divide by 12 to get the monthly amount. If you need help, leave it blank and a counselor will call you to discuss.
  • I am in need of housing services and I understand that in order to receive them I must submit an up-to-date budget estimate.*
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  • Date
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  • Should be Empty: