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/202686716532156
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
Should be Empty:

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

Post-Purchase Workshop Registration

Home Purchase Information