POST Purchase Workshop Registration Form

Post-Purchase Workshop Registration

*Please note: this class is meant for AFTER your home has been purchased. For the Pre-Purchase Workshop Registration, please visit this link: https://form.jotform.com/2229947020046
Registration Date:

MonthDayYear
Today's Date
GROUP #________________________ LOG #______________________________
Name:*

First NameLast NameSuffix
Email:*
example@example.com
Phone Number*
Please enter a valid phone number.
Have you completed any other FHAS Workshops?*

Financial EducationPre-PurchaseHousing Matters with Tenant ServicesNone of the Above
Reason for Attending:*
Current Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Different mailing addressSame mailing address
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Mortgage Status:*

Own with mortgageOwn with defaulted mortgageOwn with no mortgage (paid off)Other
Length of Occupancy:*
Monthly Payment*
(if applicable)
Date of Birth:*

MonthDayYear
Age:*
Gender:*

FemaleNon-binaryMaleOther
Highest Level of Education: *
Ethnicity:*
Race:*
Residency:*

US CitizenPermanent Resident
Country of Origin:*
Ex: South Sudan, USA, Mexico
Limited English Proficiency?*

YesNo
Primary Language:*
Disabled:*

YesNo
Veteran:*

YesNo
Retired:*

YesNo
Student:*
Marital Status:*
Co-Applicant Name:

First NameLast Name
Co-Applicant Date of Birth:

MonthDayYear
Co-Applicant Age:
Co-Applicant Gender:

FemaleNon-binaryMaleOther
Highest Level of Education:
Co-App Ethnicity:
Co-App Race:
Co-App Residency:

US CitizenPermanent Resident
Co-App Country of Origin:
Ex: South Sudan, USA, Mexico
Limited English Proficiency?

YesNo
Primary Language:
Co-App Disabled:

YesNo
Co-App Veteran:

YesNo
Co-App Retired:

YesNo
Student:
Employment Status:*
Employer:*
Insurance:*

PrivateMedicaidMedicareNo Insurance
Monthly Income (Household):*
Yearly Income (Household):*
TANF Benefits?*
Select all Federal, State, and Local benefits that apply:*

B2I StipendState BenefitsSNAP/EBTQualify for Earned Income Tax Credit (EITC)None of the above
Household Type:*
Total Household Size:*
All Adults, Children, and Dependents
Adults in Household:*
All Adults, NO Children or Dependents
Children in Household:*
ONLY Children 19 years and younger
Dependents in Household:*
ONLY Children/Dependents 19 years and OLDER

Home Purchase Information

Please complete to the best of your ability
Date of Purchase*

MonthDayYear
Mortgage Company*
If multiple, separate with commas
Loan Type: *

Home Purchase Information:*

	Amount	Lender	Monthly Payment	Loan Type
1st Mortgage
2nd Mortgage
3rd Mortgage
4th Mortgage
VA Loan
FHA Loan

Select all that apply:*

Current on PaymentsBehind on PaymentsSlow Payment HistoryConcerned about ForeclosureOther
Please complete if you are already in the process of Foreclosure. If N/A please skip
Loan/FHA/VA Number:
Mortgage Company:

Same as AboveDifferent as Above
Contact Person:

First NameLast Name
Default Reason Code:

Business Venture FailedDeath of Family MemberDivorce/SeparationIncrease in ExpensesLoss of IncomeMedical IssuesPoor Budget Mgmt SkillsReduction in Income
Loan Status:

Current30-60 Days Late61-90 Days Late91-120 Days Late121+ Days Late
Loan Product Type:

Fixed Rate Currently Under 8%Fixed Rate Currently 8% or GreaterARM Currently Under 8%ARM Currently 8% or GreaterOther
My/our signature(s) below certifies that all information provided on this Intake Form is accurate and complete to the best of my/our knowledge.
Applicant Signature:*

Clear
Co-Applicant Signature:

Clear
Today's Date*

MonthDayYear
Referred by: *
Ex: Pre-Purchase workshop, Lender, etc.
Workshop Date:*
Post-Purchase Education

__ Session 1   __ Session 2 __ Session 3    Completed Workshop: ______/______/_________

Location of Class:                                   Total Classroom Time:

Completed 1on1: ______/______/_________       Close Date: ______/______/_________

Results of Counseling:

o Bankruptcy: 7 or 11                o Mortgage Modified          o Refinanced Mortgage

o Brought Mortgage Current       o Mortgage Refinanced       o Repayment Plan

o Continue Counseling                o Obtained Rehab Loan       o Sold Property

o Executed Deed-in-lieu              o Paid off Mortgage            o Trial Modification

o Forbearance Agreement           o Partial Claim

o Information Offered                 o Received 2nd Mortgage

o Mortgage Foreclosed                o Referred to Omaha 100

Authorization to Obtain & Release Information

Family Housing Advisory Services, Inc.
This form is valid for the following workshops: Financial Education, Pre-Purchase, and Post-Purchase workshops.

I/we, {yourName} ,{coapplicantName} do hereby:
Authorize FHAS to share information about me/us, but not limited to, information provided pursuant to the terms of this Authorization to Obtain & Release Information and to speak with any person/organization, its agents and employees solely for the purpose of assisting me/us. FHAS does not release information to any third-party agencies for the purpose of marketing.
Applicant Initials*   Co-Applicant Initials
Authorize the release of any and all required information regarding each of my/our accounts and loans to any representative of Family Housing Advisory Services, Inc. (FHAS). I/we understand that the information released may include, but is not limited to, verbal, written, or printed information relating to my/our accounts(s) and payment transactions, copies of loan documents and any record of communication history associated with my/our account(s) and loan(s). I/we further authorize verbal communication and consultation with any representative of FHAS regarding all aspects of my/our account(s) and account history, including information provided by any other party.
Applicant Initials*   Co-Applicant Initials
Agree to hold FHAS harmless as a result of their good faith attempt to assist me/us and understand that FHAS will maintain the confidentiality of my/our non-public personal information in accordance with its policies and applicable federal and state law.
Applicant Initials*   Co-Applicant Initials
Refusal to sign this Authorization to Obtain and Release Information will NOT result in a denial of services, but FHAS will not be able to negotiate or obtain information on your behalf. A copy or scan of this document will be considered an original for all intents and purposes.
Applicant Signature*

Clear
Co-Applicant Signature

Clear
Primary Applicant Name: {yourName} Co-Applicant Name: {coapplicantName}
{startDate}
Current Address: {currentAddress}
Referring Agency: {referredBy}
blank

Privacy Policy

Family Housing Advisory Services, Inc.
Privacy Policy - Opt Out

If your account is active, and you are not comfortable with this level of information sharing, please contact us to inactivate your account. If your account is inactive, your information is no longer used internally or externally, except for record keeping, governmental, and audit purposes.

Direct Mail: Family Housing Advisory Services, Inc.

2401 Lake Street

Omaha, NE 68111

Phone: 402-934-6471

Attn: Donna
Privacy Policy

You are receiving this statement to comply with federal laws regarding the disclosure of non-public information. FHAS is committed to fully protecting and preserving the privacy of our clients. For your protection, please take a few moments to read this statement:

As part of our committment to your privacy, FHAS will only disclose the information that it must in order to serve you in the most effective manner possible. Hence, FHAS will not distribute client information to third parties, except where it is necessary to perform quality services or its clients, as described below.

This Applies To

This statement applies to those individuals who have received education and/or one-on-one counseling assistance, and with whom there is a continuing counselor/client relationship.

Information Collected

Through telephone, fax, mail, and electronic communication, personal information will be gathered, including address, social security number, telephone number, email address, and other demographic information. Through the aforementioned channels, financial information will also be collected, including information related to your debts, income, expenses, and checking/savings accounts on an as-needed basis. Please be assured that we carefully train all of our counselors to carefully protect all client information. In order to do this effectively, we will ask for information that only you should know when you contact us. No one else can call in and access your information without your written authorization. If you find, at any time, that our records contain inaccurate or incomplete records, please let us know immediately.

Internal Sharing

Information may be shared with FHAS as needed to assist with situations that may arise.

External Sharing

A necessary portion of your personal and financial information will be used to communicate with your creditors and/or lender to coordinate with them on your behalf. Information will not be sold to corporations. FHAS does not report any information to credit bureaus.

Other Applicable Laws

The practices described above are in accordance with federal privacy law. You may have other protections under applicable state laws. To the extent that these state laws apply, we will comply with them when we share information about you.

Protections for Information

Physical andelectronic files are only kept within the confines of the FHAS offices and at approved secure backup sites. Access is restricted to authorized personnel only.

Information Storage

The information you supply FHAS will remain in corporate files for as long as it is necessary to provide services, and for a reasonable period of time following the completion or termination of services.

Online Privacy

Information may be gathered when you visit the FHAS website, including Internet Protocol (IP) addresses, Uniform Resource Locator (URL) tags, and basic operating system and browser information. Electronic security is maintained through use of firewalls (which are designed to protect systems from intrusion). All information collected through the Jotforms website is encrypted upon submission and is not sold to third-party affiliates per a licensed BAA between both parties.

Notes

FHAS refers to the Family Housing Advisory Services, Inc. a Housing and Urban Development (HUD) Housing Counseling Agency. FHAS is also an agency of United Way of the Midlands.

How You Can Help Protect Your Privacy

Do not share your account information, passwords, user IDs, PINs, your SSN, code words or other confidential information with others.

Do not provide confidential information to unknown callers.
Do not provide confidential information online unless YOU initiated the contact, know the party with whom you're dealing, and can provide the information through a secure line (https://).
When conducting business over the internet, always use a secure browser & exit onlineapplications as soon as you finish using them.
If you believe you have been the victim of identity theft or fraud, please call the Social Security Administration Fraud Hotline at 800-397-0271 to report fraudulent use of your identification information.
File a complaint with the Federal Trade Commission (FTC) by contacting the FTC's Identity Theft Hotline: 877-ID-THEFT (877-438-4338).
File a police report and retain the police report number and officer's name and badge number that took the report.

Credit Bureau Fraud Lines:

Experian: 888-397-3742

Equifax: 800-525-6285

TransUnion: 800-680-7289

I/we acknowledge that I/we received, read, and agree to Family Housing Advisory Services, Inc.'s Program Privacy Policy.
Applicant Signature:*

Clear
Co-Applicant Signature:

Clear

HUD Program Disclosure Form

This form is valid for the following workshops: Financial Education, Pre-Purchase, and Post-Purchase.
Note: If you have an impairment, diability, language barrier, or otherwise require an alternative means of completing this form or accessing information about arranging alternative accomodations, please talk to your housing counselor about arranging alternative accomodations.

About Us And Program Purpose

Family Housing Advisory Services, Inc. (FHAS) is a nonprofit, Housing and Urban Development (HUD) approved comprehensive housing counseling agency and also an agency of the United Way of the Milands. We provide education workshops and a full-spectrum of housing counseling services including: Pre-Purchase, Post-Purchase, Foreclosure Prevention, Financial Education, Individual Development Account (IDA), Earned Income Tax Credit, Fair Housing, Rental, Homeless Prevention, Utility Assistance, Family Support, and Opportunity Passport™ Program.

We serve all clients regardless of income, race, religion/creed, national origin, age, family status, disability, or sexual orientation/gender identity. We administer our programs in confirmity with local, state, and federal anti-discrimination laws. The roles and responsibilities of the Client and Counselor are listed below.

*In the designated areas on this form, please initial/sign and date.*
Client & Counselor - Roles & Responsibilities

COUNSELOR

Roles & Responsibilities

CLIENT (YOU)

Roles & Responsibilities

Review your housing goal and your finances; which include your income, debts, assetts, and credit history
Prepare a Client Action Plan that lists the steps that you and your counselor will take in order to achieve your housing goal
Prepare a household budget that will help you manage your debts, expenses, and savings
Your counselor is not responsible for achieving your housing goal, but will provide guidance and education in support of your goal
Your counselor is not authorized to provide legal advice

Complete the steps assigned to you in your Client action plan
Provide accurate information about your income, debts, expenses, credit, and employment
Attend meetings, return calls, respond to emails, provide requested paperwork in a timely manner
Notify your counselor when changing housing goal
Attend education workshop(s) [i.e. pre-purchase education and/or financial management] as reccomended
Seek legal advice and/or representation if legal assistance is needed beyond what the General Counsel at FHAS can offer

Termination of Services: Failure to work cooperatively with your Housing Counselor will result in the discontinuation of services. This includes, but is not limited to, missing three (3) consecutive appointments.
Primary Initial here* {startDate} Co-Applicant Initial here {startDate}
{email}
AGENCY CONDUCT: No FHAS employee, officer, director, volunteer or agent shall undertake any action that might result in, or create the appearance of, administering counseling operations for personal or private gain, provide preferential treatment for any person or organization, or engage in conduct that will compromise our agency's compliance withfederal regulations and our committment to serving the best interests of our Clients.

AGENCY RELATIONSHIPS: FHAS has an affiliate organization, Omaha 100, which is a community mortgage lending institution. FHAS also has financial affiliation with HUD and the City of Omaha and other funders to administer Pre-Purchase, Post-Purchase, an Financial Education counseling. FHAS also receives education fees from the Federal Home Loan Bank down payment asistance program. As a housing counseling participant, you are not obligated to use any of the products or services discussed int he workshops and counseling services will still be provided. You are entitled to choose whatever real-estate professionals, lenders, and lending products that best fit your needs. A list of our partner relationships and workbook fees are posted in the classrom.

FHAS also administers Opportunity Passport which is a matched savings, asset-building program that includes financial literacy education and asset-specific training. It is a program of Project Everlast that is administered by FHAS to help young adults transitioning from foster care to becoming financially capable. Financial support for Opportunity Passport is provided by Nebraska children and Families Foundation, Sherwood Foundation, William and Ruth Scott Family Foundation, and the Department of Health & Human Services (DHHS).

REFERRALS AND COMMUNITY RESOURCES: FHAS can provide a community resource list which outlines services to meet a variety of needs. FHAS staff can also provide you with a list of agencies that provide services and programs similar to those offered by FHAS.

PRIVACY POLICY: It is a violation of our policy to discuss client information with anyone who does not have a direct association with resolving the issue(s).

QUALITY ASSURANCE: In order to assess Client satisfaction, a FHAS staff member may contact you during or after the completion of your counseling service(s). You may be asked to complete a survey to evaluate your Client experience.

HOME INSPECTIONS: Home inspection materials are provided at the workshop and also during the one-on-one.

I/we acknowledge that I/we received, reviewed, and agree to the Family Housing Advisory Services Program Disclosures.
Applicant Signature:*

Clear
Co-Applicant Signature:

Clear

	$20,000 or below (VLOW)	$33,000 or below (LOW)	$39,960 or below (MOD)
Household Size: 1 Person

	$22,850 or below (VLOW)	$38,050 or below (LOW)	$45,660 or below (MOD)
Household Size: 2 People

	$25,700 or below (VLOW)	$42,800 or below (LOW)	$51,360 or below (MOD)
Household Size: 3 People

	$28,550 or below (VLOW)	$47,550 or below (LOW)	$57,060 or below (MOD)
Household Size: 4 People

	$30,850 or below (VLOW)	$51,400 or below (LOW)	$61,680 or below (MOD)
Household Size: 5 People

	$33,150 or below (VLOW)	$55,200 or below (LOW)	$66,240 or below (MOD)
Household Size: 6 People

	$35,450 or below (VLOW)	$59,000 or below (LOW)	$70,800 or below (MOD)
Household Size: 7 People

	$37,700 or below (VLOW)	$62,800 or below (LOW)	$75,360 or below (MOD)
Household Size: 8 People

US Citizenship Attestation Form for Public Benefit

This form is valid for the following workshops: Financial Education, Pre-Purchase, and Post-Purchase.
PRIMARY APPLICANT: For the purposes of complying with Neb. Rev Stat. §§ 4-108 through 4-114, I attest as follows:*

I am a citizen of the United StatesI am a qualified alien under the Federal Immigration and nationality Act. My immigration status and alien number are as follows:
Immigration Status*
Permanant Resident Alien Number
Applicant Signature*

Clear
Today's Date*

MonthDayYear
Date
CO-APPLICANT: For the purposes of complying with Neb. Rev Stat. §§ 4-108 through 4-114, I attest as follows:

I am a citizen of the United StatesI am a qualified alien under the Federal Immigration and nationality Act. My immigration status and alien number are as follows:
Immigration Status
Permanant Resident Alien Number
Co-Applicant Signature

Clear
Today's Date

MonthDayYear
Date
Should be Empty:

	Gender	Age	Ethnicity	Race	Disabled	Employed	In School
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6

	a. Wages/Salaries	b. Benefits/Pensions	c. Public Assistance	d. Other Income	e. Assets Income
Head of Household
Household Income 2
Household Income 3
Household Income 4
Household Income 5
6. TOTALS
Enter total items from 6a. - 6e. for ANNUAL INCOME

Post-Purchase Workshop Registration

Home Purchase Information

Authorization to Obtain & Release Information

Privacy Policy

HUD Program Disclosure Form

Client & Counselor - Roles & Responsibilities

Household Data Survey

US Citizenship Attestation Form for Public Benefit