2021_ Housing Service INTAKE Application

== We Are All In This Together!!! ==

SERVICE INTAKE APPLICATION:

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 how our services may help you answer your housing questions & concerns before they become critical;

(2) Stay up-to-date and/or ask questions to ensure you are on a "Housing Recovery Path" after the CRISIS has subsided. NOTE: Housing Assistance Grants are a "Rescue" Recovery is just as important;

(3) If you are a Home Owner or Renter , you will learn about and understand available Options such as Modification vs Forbearance, Grant Application Assistance, Rental Assistance, etc.;

All information is transmitted directly to AGORA securely and held in strict privacy for your protection. Your information is not shared with anyone. Please enter N/A, if a question does not apply.

We thank you for entrusting AGORA to assist you in your housing journey.

Full Name*

First NameLast Name

Co-Borrower, Co-Tenant

First NameLast 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*

Address*

Street Address

Suite or Apt Number

CityState / Province

Postal / Zip CodeCountry

Marital Status*

Head of Household?*

Social Security Number - LAST 4 Digits ONLY*

Last 4 Digits ONLY

Phone Number*

Area CodePhone Number

Birth Date*

MonthDayYear

Phone Type*

Can We Text Appt. Reminders?*

Type YES or NO

Best time to contact you for follow-up.*

Gender*

MaleFemaleChoose not to respond

E-mail*

example@example.com OR ENTER: N/A, No Email@gmail.com, if you do not have an email that you monitor

Ethnicity*

HispanicNon-Hispanic

Race*

Education*

Language*

EnglishSpanishOther

Veteran*

Live in Rural Area*

Preferred Language*

Limited English*

Household Annual Gross Income*

Less than $25,000$25,500 - $41,500$41,600 - $61,500Over $61,000

Number in Household?*

Filed Bankruptcy or Considering Filing Bankruptcy? *

A Bankruptcy: Type Discharged or Dismissed? *

Current Status of Bankruptcy Process or Court Date / or N/A

Type of Bankruptcy?*

Chapter 7Chapter 13N/A

Please check all that describes areas of assistance needed:*

INTAKE APPOINTMENT (In-Person) if you do not have computer access OR homebound and need a HomeVisit Scheduled. Provide Day & Time best for you and we will try to accomodate you.*

READY TO GET STARTED? Check you email for your Next Step to set up your Service File*

Enter YES or NO

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. CLICK SUBMIT TO COMPLETE.