Foreclosure Prevention Counseling Form

Dear Homeowner:

Thank you for choosing Clinch - Powell to help you work through this difficult time. This program is provided to you free of charge because of funding received from government programs. In order to keep this service free, Clinch - Powell must follow certain program guidelines which often include specific forms and documentation.

After we receive your completed packet, please allow several business days for an intake specialist to review your documents and contact you via e-mail with any follow - up questions. Only after ALL your documents are received will it be processed by a certified housing counselor—unless you have a Date of Sale on your home, in which case, call our office immediately.

You will be provided a list of supporting documents and where to upload them by email upon completion of this form.

HOUSING ASSISTANCE APPLICATION-- MORTGAGE
HOMEOWNER
Full Name*
Home/Cell Phone*
E-mail Address *
By providing an e-mail address, you attest it’s secure & you can & will check it regularly
Would you like to add a Co-owner and/or Spouse to this application?

Co-ownerSpouse
CO-HOMEOWNER or SPOUSE
Mr./Ms. Name*
Home/Cell Phone*
E-mail Address*
By providing an e-mail address, you attest it’s secure & you can & will check it regularly
Household
Street Address*
PO Box
City/State*
Zip-Code*
County*
How long at residence?*
Number of people in the household*
Primary language spoken
AUTHORIZATION TO CONTACT AND RELEASE INFORMATION
I/We are authorizing communication with the following in order to receive housing assistance:
Authorization to contact Mortgage/Servicer Company

I/We Authorize
Mortgage/Servicer Company Name
Company Phone number
Mortgage loan is in the name(s) of
Account #
Authorization to contact Referral Agency

I/We Authorize
Company
Contact person
Phone number(s)
Email
example@example.com
Authorization to contact other organization (Homeowner insurance, Homeowner Association, Trustee, Utilities, Etc)

I/We Authorize
Organization Type
Company Name
Company phone number
Account is in the name(s) of
Account #
I/We, hereby authorize agents of Clinch-Powell RC&D Council (Tax ID #62-1396815), a HUD Certified Housing Counseling Agency #82934, HUD-Certified counselors Susan Eribarne or Elizabeth Grisham to discuss my accounts Additionally, I authorize the sharing of any necessary information and documentation as needed for receipt of housing counseling services, program participation and eligibility. Information may be provided via preferred communication channels of either party, including, but not limited to: verbally, electronically, and print. I further agree that a photocopy, scan, or facsimile fax of this document will also serve as authorization for release of information. This authorization will expire 36 months from the date below.
Homeowner/Co owner names*
Homeowner Signature*

Clear
Co-owner/Spouse Signature*

Clear

Rows	"Other" Debt Type	Company Name	Total Balance Owed	Interest Rate	Monthly Payment	Allowable Minimum Payment	# of months to pay off
Auto
Auto
Credit card
Other
Other
Other
Cash advance payday loans
Appliance/ furniture payments
Student loan payments

HOUSING ASSISTANCE APPLICATION-- MORTGAGE

HOMEOWNER

CO-HOMEOWNER or SPOUSE

Household

AUTHORIZATION TO CONTACT AND RELEASE INFORMATION

Homeowner Information

Homeowner optional demographic info

Homeowner employment

Co-owner and/or Spouse Information

Co-owner and/or Spouse optional demographic info:

Co-owner Employment

Other household income:

Assets (and approximate values)

DISCLOSURE & CONFLICT OF INTEREST

PRIVACY POLICY NOTICE

Housing Counseling Agreement & Authorization

Monthly Household Expenses Worksheet

Housing Expenses

Living Expenses

Monthly installment debt