2021_ Housing Service INTAKE Application

CO VID-19 == We are In this Together!!!

We invite you to share these services with Friends, Family and Neighbors. Below, you will have an opportuity to:

(1) Housing Service Orientation is an important start to understand your housing services and STEP ONE to obtain assistance in reaching a housing resolution.

(2) Stay up-to-date and/or ask questions to ensure you are on a "Housing Recovery Path" after the CRISIS has subsided.

(3) Understand your next steps and Options such as Modification vs Forbearance, Grant Application Assistance etc.

All information is transmitted directly to AGORA securely and held in strict privacy for your protetion. Your information is not shared with anyone.

We thank you for contacting AGORA.
Full Name *

First Name Last Name
" YOUR STORY " Help us understand your concern. Describe your concern and the result that you are looking to achieve. *
" Your Story" Explain the concern or question you have concerning housing.
Service Type *

HOMEOWNER LANDLORD HOME BUYER RENTER REVERSE MORTGAGE INFORMATION AVOID HOMELESSNESS IMPROVE CREDIT BUDGET & FINANCIAL CAPACITY BUILDING FINANCIAL ASSISTANCE RESOURCES HOME REPAIR
Address *

Street Address

Suite or Apt Number

City State / Province

Postal / Zip Code Country
Marital Status *
Head of Household? *
Social Security Number - LAST 4 Digits ONLY *
Last 4 Digits Only
Phone Number *

Area Code Phone Number
Birth Date *

Month Day Year
Phone Type *
Can We Text Appt. Reminders? *
Type YES or NO
Best time to contact you for follow-up. *
Gender *

Male Female Choose not to respond
E-mail
example@example.com OR Type N/A, if you do not have an email that you monitor
Ethnicity *

Hispanic Non-Hispanic
Race *

Am Indian /Alaskan Native Am Indian / Alaskan Native and Black Am Indian/ Alaskan Native White Asian Asian and White Black or African American Black or African American and White White Native Hawaiian or Other Pacific Islander Hispanic Choose not to respond
Education *
Language *

English Spanish Other
Veteran *
Live in Rural Area *
Preferred Language *
Limited English *
Household Annual Gross Income *

Less than $25,000 $25,500 - $41,500 $41,600 - $61,500 Over $61,000
Number in Household? *

1 2 3 4
Filed Bankruptcy or Considering Filing Bankruptcy? *
Bankruptcy Discharged or Dismissed? *
Current Status of Bankruptcy Process or Court Date
Type of Bankruptcy? *

Chapter 7 Chapter 13 Undecided, No Bankruptcy Filed
Please check all that describes areas of assistance needed: *

SAVING Home Mortgage Review Home Repairs Fraud Avoidance Help with Home Property Taxes Improve Credit General Home Organizing Financial Organizing Senior Resources Assistance with a Housing Grant Application Computer /Internet Assistance Food
READY TO GET STARTED? Select the Date & Time below. *
Enter YES or NO
Appointment 1st Choice *
Time *

: Hour Minutes AM/PM Option
2nd Appointment Choice
Need Special Assistance *
SIGNATURE Authorizing Services and Credit Authorization : *
Your Typed Name above will represent Signature Authorization and, if applicable. If you cannot type your Name above, hitting submit below will represent your Signature Autorization. HIT SUBMIT TO COMPLETE.
Should be Empty: