Language
English (US)
Spanish (Latin America)
CUSTOMER INTAKE FORM
NOT considered a Housing Program Application. Please turn in the 2 most recent pay stubs (you will have the opportunity to upload documents at the end of the form)
I am interested in living in
Bend
Redmond
Either
I have watched the Informational videos on the website
Yes
Video Code #1
to verify that you have watched the videos
Video Code #2
If you cannot find the code, please verify that you have watched the video
PRIMARY CUSTOMER INFORMATION
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Social Security Number
*
Needed for Soft Credit Pull
Ethnicity
Hispanic/Latino
Non-Hispanic/Latino
Race (Please Check one)
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Asian
White
Black or African American
Two or More Races
Other
Citizenship (Please select one)
I am a Citizen or National of the United Sates
I am Foreign Born AND a US Resident (green card)
I am a non-Citizen with eligible status as evidenced by one of the following documents: Form I551 (Alien Registration Receipt Card for permanent resident aliens), or Form I-94 Arrival-Departure Record, or a final court decision or DHS letter granting asylum
None of the Above: I am not contending eligible immigration status (no further information required), and I understand that I am not eligible for the Bend-Redmond Habitat for Humanity program. HOWEVER, I agree to start Housing Counseling while immigration status changes.
Marital Status
Single
Married
Separated (with legal separation documents)
Separated (but do not have legal separation documents)
Divorced
Widowed
Gender
Male
Female
Other
Education
Below high school diploma
High School Diploma or GED
Two-Year College
Bachelors Degree
Masters Degree
Above Master's Degree
Other
Do any of the following apply to you (optional for data collection/often asked on grant reports). Check all that apply.
Hearing difficulty (deaf or have serious difficulty hearing)
Vision difficulty (blind or have serious difficulty seeing, even when wearing glasses)
Cognitive difficulty (because of a physical, mental, or emotional issue, have difficulty remembering, concentrating, or making decisions)
Ambulatory/Movement difficulties (have serious difficulty walking or climbing stairs))
Self-care (have difficulty bathing or dressing on own)
Domestic Violence Victim
Have recovered from substance abuse
Are you a Veteran? (please select one)
Yes
No
Other
Current Housing Arrangement (please select one)
Renting
Homeless
Living with Family or friends and NOT paying rent)
Living with family or friends and sharing rent
Other
Do you currently have health insurance?
Yes
No
If no health insurance, why?
Have you owned a home (or been on the title of a home loan) in the last 3 years?
Yes
No
Household Type
Female single parent household
Married with children
Married without children
Single
Two or more unrelated adults
Male single parent household
Household size (include those that will be living in the household 50% or more of the time)
How many dependents (those claimed on taxes and other than those listed by co-customer)
What ages are the dependents?
Do all the dependents have health care insurance?
Yes
No
If no, why?
Are the other non-dependents who will be living in the home? Note: all adults 18 and older in the household must submit financial documents (such as pay stubs) so that we can determine household income.
Yes
No
If yes, list the relationship and age of non-dependent 1
If yes, list the relationship and age of non-dependent 2
How did you hear about us?
Print Ad/Newspaper
Radio
Television
Habitat Staff or Board Member
Walk-in
Family/Friend
Social Media
Other
PRIMARY CUSTOMER EMPLOYMENT
Last two years
Employer Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Job Title
Hire date
Month/Day/Year
Employment Status (Please check one)
Part-time
Full-time
Other
Hours per pay period (average)
Gross Monthly Income (before taxes)
How are you paid
Hourly
Salary
If hourly, how much per hour?
If salary, how much per month?
How often are you paid?
Weekly
Every 2 weeks
Twice per month
Once a month
IF APPLICABLE, second Employer Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Job Title
Hire Date
Month/Day/Year
Employment Status
Part-time
Full-time
Hours per pay period
Gross Monthly Income (before taxes)
How are you paid?
Hourly
Salary
If hourly, how much per hour?
If salary, how much per month?
How often are you paid?
Weekly
Every two weeks
Twice per month
Once a month
Previous Employer Name
Previous Employer Phone
Please enter a valid phone number.
Previous Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Previous Employer Phone Number
Please enter a valid phone number.
Job Title
Dates of previous Employment
Month/Day/Year to Month/Day/Year
Type of Empyoyment
Part-time
Full-time
Type of Pay
Hourly
Salary
Hours per pay period
Amount paid per hour
If Salary, leave blank
Gross Monthly Income (before taxes)
How often were you paid?
Weekly
Twice a month
Every two weeks
Once per month
Co-Customer Information
If none, leave blank and skip to next section
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Social Security Number
Needed for soft credit pull
Ethnicity
Hispanic/Latino
Non-Hispanic/Latino
Race (Please Check one)
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Asian
White
Black or African American
Two or More Races
Other
Citizenship (Please select one)
I am a Citizen or National of the United Sates
I am Foreign Born AND a US Resident (green card)
I am a non-Citizen with eligible status as evidenced by one of the following documents: Form I551 (Alien Registration Receipt Card for permanent resident aliens), or Form I-94 Arrival-Departure Record, or a final court decision or DHS letter granting asylum
None of the Above: I am not contending eligible immigration status (no further information required), and I understand that I am not eligible for the Bend-Redmond Habitat for Humanity program. HOWEVER, I agree to start Housing Counseling while immigration status changes.
Marital Status
Single
Married
Separated (with legal separation documents)
Separated (but do not have legal separation documents)
Divorced
Widowed
Gender
Male
Female
Other
Education
Below high school diploma
High School Diploma or GED
Two-Year College
Bachelors Degree
Masters Degree
Above Master's Degree
Other
Do any of the following apply to you (optional for data collection/often asked on grant reports). Check all that apply.
Hearing difficulty (deaf or have serious difficulty hearing)
Vision difficulty (blind or have serious difficulty seeing, even when wearing glasses)
Cognitive difficulty (because of a physical, mental, or emotional issue, have difficulty remembering, concentrating, or making decisions)
Ambulatory/Movement difficulties (have serious difficulty walking or climbing stairs))
Self-care (have difficulty bathing or dressing on own)
Domestic Violence Victim
Have recovered from substance abuse
Are you a Veteran?
Yes
No
Other
Relationship to Primary Customer
Partner/Significant Other
Husband/Wife
Mother/Father
Sibling
Son/Daughter
Other
Back
Next
Save
Co-Customer Employment Information
Employer Name
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer Phone Number
Please enter a valid phone number.
Job Title
Hire Date
Employment Status (Please check one)
Part-time
Full-time
Other
How are you paid?
Hourly
Salary
Hours per pay period (average)
Amount paid per hour
If Salary, leave blank
If salary, amount paid per month (gross)
Gross Monthly Income (before taxes)
How often are you paid?
Weekly
Every two weeks
Twice a month
Once a month
IF APPLICABLE, Second Employer Name
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer Phone Number
Please enter a valid phone number.
Job Title
Hire Date
Month/Day/Year
Employment Status
Part-time
Full-time
How are you paid?
Hourly
Salary
Amount paid per hour
If Salary, leave blank
If Salary, Amount paid per month
Hours per pay period
Gross Monthly Income (before taxes)
How often are you paid?
Weekly
Every two weeks
Twice per month
Once a month
Customer Previous Employer
Previous Employer Name
Name
Last Name
Job Title
Length of Employment
Date to Date
Previous Employer AddressAddress
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Previous Employment was
Part Time
Full Time
Hours per pay Period
Gross Monthly Income
How were you paid?
Hourly
Salary
If hourly, amount paid per hour
If paid salary, gross amount paid per month
How often were you paid?
Weekly
Every two weeks
Twice a month
Monthly
Please list all sources of income (include for all adults, 18 and older, in the household)
Primary Customer
Co-Customer
Other Adult in Household
Salary, Wages (Inc. tips)
Alimony, Child Support (for those younger than 16 years of age)
Social Security, SSI/SSDI
Pension, Retirement
Public Assistance (TANF)
Housing Voucher (list award amount and provide copy of voucher letter)
Dependent Income (SSI, SSDI)
Self-Employment Income (list amount from Schedule C of Tax Return)
Other Employment (if at least one year)
Estimated Gross Monthly Household Income
LIQUID ASSETS/SAVINGS/INVESTMENTS
Please list the approximate and/or current values
Primary Customer
Co-Customer
Other Adult in Household
Checking Account 1
Checking Account 2
Savings Account
Cash (not in any accounts)
CD's
Securities (stocks, bonds)
Retirement Account
Other Liquid Funds
Monthly Housing Expenses
Household
Current Monthly Rent (if using a housing voucher, list the portion you pay)
Utilities (Average)
Internet/Cable
Other Living Expenses
Other
ATHORIZATION TO RELEASE CREDIT INFORMATION
Liabilities and debt will be determined by what shows on Soft Credit Pull
I authorize the Housing Counseling Staff of Bend-RedmondHabitat for Humanity to: (a) pull my/our credit report (soft pull; will not affect your score) toreview my/our credit file for housing counseling in connection with my pursuiton a loan to purchase real property; (b) pull my/our credit report (soft pull) and review my/our credit file forinformational inquiry purposes; and (c) obtain a copy of the HUD-1 Settlement Statement, Appraisal, and RealEstate Note(s) when I/We purchase a home, from the lender who made me/us a loanand/or the title company that closed the loan.I/We understand that any intentional or negligentrepresentation(s) of the information contained on this form may result in civilliability and/or criminal liability under the provisions of Title 18, UnitedStates Code, Section 1001.
Yes
No
Primary Customer Signature
Clear
Date
Month/Day/Year
Co-Customer Signature
Clear
Date
Month/Day/Year
Please upload income documents for all adults in household. Also, if you have a housing voucher, please upload copy of your award letter
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Are there other concerns that you would like to address in a Client Mortgage Counseling Session? If so, list below
Please allow 2-4 days for response from Homeowner Services Department
Once we have reviewed your form and the soft pull, we will reach out to you by email to schedule a one-on-one Intake appointment to set goals and to review your mortgage readiness.
Preview PDF
Save
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform