Workshop Registration Form

Workshop Registration Form

Pre-Purchase and Financial Education Workshops
Start Date

MonthDayYear
Date
Thank you for your interest in the Pre-Purchase and/or Financial Education Workshops!

Please complete the forms below in its entirety and choose your workshop date(s) at the bottom. Next, you will need to complete the pre-workshop paperwork attached to this registration on the next pages. The estimated time to complete all of the forms is around 15 minutes.

A FHAS Staff Member will reach out to you via email within 5 business days or less to confirm your seat in the workshop you have selected.
Referred by:*
If Other Agency, please list here:
Please list referring agency if not on the list above
Are you a first-time home buyer?*

YesNo
Case Worker Name
If you are working with a caseworker and want your certificate emailed to them, please list name here
Caseworker Email
example@example.com
What other programs are you currently working with? (Please select all that apply)*

Pre-PurchaseFinancial EducationThis is my first time working with Family Housing Advisory Services.
About You
Your Name*

First NameMiddle NameLast NameSuffix
Phone Number*
Please enter a valid phone number.
OK to text?*

YesNo
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Current Age*
Gender*

FemaleMaleNon-binaryTransgenderOther
Select All That Apply (Disabled/Veteran/Retired/Student/LEP):*

DisabledVeteranRetiredFT StudentPT StudentLimited English ProficiencyNone of the Above
Primary Language*
Highest Level of Education*
Residency*

U.S. CitizenPermanent Resident AlienOther
Country of Origin*
Ethnicity*

HispanicNot Hispanic
Race*
Marital Status*
Please Note: Co-Applicant information is required if you have selected Married, Separated or CoHabitating
Co-Applicant Name*

First NameLast Name
Co-Applicant DOB*

MonthDayYear
Date
Co-Applicant Age*
Co-Applicant Gender*

FemaleMaleNon-BinaryTransgenderOther
Co-Applicant Primary Language:*
Co-Applicant Country of Origin:*
Co-Applicant Ethnicity*

HispanicNot Hispanic
Co-Applicant Race*
Co-Applicant Residency*

U.S. CitizenPermanent Resident AlienOther
Co-Applicant - Select All That Apply (Disabled/Veteran/Retired/ Student/LEP)*

DisabledVeteranRetiredFT StudentPT StudentLimited English ProficiencyNone of the Above
About Your Residence
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address*

Same as aboveDifferent mailing address
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Living Arrangements*

RentOwn with mortgageOwn paid off mortgageFoster CareLiving with friends/family (no rent)Other
Length of Occupancy*
Ex: 2 years, 7 months
Rent Amount*
Ex: $1000/month
Pre-Approved for Mortgage*

YesNoSeeking Pre-Approval currently
Pre-Approval Amount & Lender Name
HUD Assistance*
Interested in obtaining info on Deferred Loan Payments?*

YesNo
About Your Income
Employment Status:*
Employer*
Insurance*
Monthly Income*
Include any Co-Applicant Income
Annual Income*
Include any Co-Applicant income
Benefits*

State BenefitsB2ITANF benefitQualify for Earned Income Tax Credit (EITC)NoneOther
Current Assets*

Checking accountSavings accountAsset(s) over $10kCredit Card(s)Installment Loan(s)Mortgage Loan(s)Line(s) of CreditNone of the above
Current Debts*

Collection(s)Judgement(s)Medical Bill(s)Charge off(s)BK Ch 7BK Ch 13Debt Repayment PlanPay Day LenderOwe Child SupportOwe IRSStudent Loan(s)Buy Here/Pay HereBounced ChecksNone of the AboveOther
About Your Family
Please review the Household Types below

and select yours from the dropdown

Single Adult = No children, living alone

Female or Male headed household = One adult with children (no partners)

Married with Dependants = Two married adults with children

Married without children = Two married adults with no children

CoHabitating = Living with unmarried partner(s), may have children or not

Two or More Unrelated Adults = Living with roommate(s), may have children or not
Household Type*
Total Household Size (all adults and children)*
Adults in Household (do NOT include adult dependents)*
Children - 18 and under*
Adult Children - 19 and older*

Pre-Purchase & Financial Education Workshops

Please select a workshop you would like to attend. More than one workshop can be selected.
What workshop(s) would you like to attend?*

Pre-Purchase WorkshopFinancial Education Workshop
Pre-Purchase Workshop

Please select a pre-purchase workshop date from the pull-down menu below.
Pre-Purchase Workshop Date
Pre-Purchase Workbook

Sponsored by Pinnacle Bank
Pre-Purchase Workbook

Sponsored by Pinnacle Bank through the July 2024 workshop. Beginning with the August 2024 workshop, the regular $30 workbook fee will be the client's responsibility or, if applicable, covered by the program's referral
Pre-Purchase Workbook $30*

I will be paying for my own book.Bill to Agency (Enter agency name below.)
Agency Name*
Required if "Bill to Agency" was selected above.
Financial Education Workshop

Please select a financial education workshop date from the pull-down menu below.
Financial Education Workshop Date
Financial Education Workshop Date - Virtual (Teams)
Financial Education Workbook Type

Paper copy - $20
My/Our signature(s) certify that all the information provided on this intake form is accurate and complete to the best of my/our knowledge.

Failure to attend a scheduled Financial Education, or Pre-Purchase Education workshop, OR, rescheduling a workshop 3 consecutive times within a calendar year, will result in ineligibility to schedule a workshop until the following calendar year.
I/We understand that if I/we miss or reschedule three consecutive workshops, I/we will not be eligible to schedule a workshop until the beginning of the next calendar year.*

I Agree
Applicant Signature*

Clear
Co-Applicant Signature

Clear

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}
FHAS Employee (for office use only):

___________________________

Family Housing Advisory Services, Inc.

MAIN OFFICE

2401 Lake Street

Omaha, NE 68111

402.934.7921/Fax 402.934.7928

Increasing Affordable Housing Opportunities for All

Certified by the United States Department of Housing and Urban Development (HUD) to provide comprehensive Housing Counseling Service. TTD Access via the Nebraska Relay System. Rev.2022

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 and electronic 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
Primary Applicant Name: {yourName} Co-Applicant Name: {coapplicantName}
Date: {startDate}

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 accommodations, please talk to your housing counselor about arranging alternative accommodations. In the designated areas on this form, please initial, sign, and date.

About FHAS 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 Midlands. 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, and Family Support.

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 conformity with local, state, and federal anti-discrimination laws. The roles and responsibilities of the Client and Counselor are listed below.
Client & Counselor Roles & Responsibilities

Counselor Roles & Responsibilities

Client's Roles & Responsibilities

Review housing goals and finances. May include income, debt, assets, and credit history
Prepares Client Action Plan that list steps to take to acheive your goals
Prepare budget to help you manage expenses and savings
Your counselor will provide guidance, education, and information in support of your goals
Your counselor can provide guidance to goals and access to resources
Your counselor will not provide any legal advice in any aspect(s)

Complete the steps assigned to complete the goals that is set up
Provide accurate information on expenses, income, employment, and other household assets
Attend scheduled meetings, return calls, and provide requested information in a timely manner
Update your goals with your counselor
Complete education workshops/classes (pre-purchase workshop, financial education workshop, etc)
For legal inquiries please seek legal advice outside of FHAS

Termination of Services: Failure to work or cooperate with your assigned housing counselor will result in the immediate termination and removal of counseling services. This includes missing three (3) scheduled meetings. A FHAS staff employee will make three (3) attempts to contact you before the file is closed. Your file will be reopened if you choose to resume service with FHAS at a later date.
Primary Initial here* {startDate} Co-Applicant Initial here {startDate}
{email}
Family Housing Advisory Services serve all clients regardless of income, race, ethnicity, religion, sex, national origin, age, familial status, disability, and/or sexualgender orientation.

Disclosure Form 2023
Family Housing Advisory Services Program Disclosure
Agency Conduct: No FHAS personnel, officer, director, volunteer or agent shall undertake any act that might result in, or create the appearance of, administering counseling operations for personal or private gain, provide preferential treatment for any person, organization, agency, or engage in conduct that will compromise our agency's compliance with federal, state, and local laws & regulations and our committment to serving the best interests of our clients and their families.

Agency Relationships: FHAS also has financial affiliation with HUD, the City of Omaha and other funders to administer pre-purchase, post-purchase, and financial education and 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, service, or partners discussed in our workshops, counseling sessions will still be provided. As a client, you are entitled to seek and choose your own real estate professional, lender, and lending products that you qualify for and that best fit your needs. A list of our partner relationships and workbook fees are posted in the classrom, (at select areas).

Referrals and Community Resources: FHAS can provide a community resource list which outlines services to meet a variety of needs. FHAS staff can provide you with a list of organizations and agencies that provide similar services to those offered by FHAS, outside services might be a cost to you, and such resource list can be found in the lobby of FHAS located at 2401 Lake Street, 2nd Floor Receptionist Area.

Privacy Policy: Please see our privacy policy statement. FHAS does not share your information without written or verbal consent, any shared information will be in violation of this policy.

Quality Assurance: To assess client satisfaction, a FHAS Staff Member, Employee, or Intern may contact you during or after the completion of your counseling service. You may be asked to complete a survey to evaluate your client experience with your housing counseling, ease of resource referral, and other experiences throughout your time with FHAS.

Home Inspection (if applicable): Home inspection materials are provided at the workshop and also during your one-on-one housing counseling.

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
Primary Applicant Name: {yourName} Co-Applicant Name: {coapplicantName}
Date: {startDate}

	$21,150 or below (VLOW)	$35,250 or below (LOW)	$56,400 or below (MOD)
Household Size: 1 Person

	$24,200 or below (VLOW)	$40,300 or below (LOW)	$64,450 or below (MOD)
Household Size: 2 People

	$27,200 or below (VLOW)	$45,350 or below (LOW)	$72,500 or below (MOD)
Household Size: 3 People

	$30,200 or below (VLOW)	$50,350 or below (LOW)	$80,550 or below (MOD)
Household Size: 4 People

	$32,650 or below (VLOW)	$54,400 or below (LOW)	$87,000 or below (MOD)
Household Size: 5 People

	$35,050 or below (VLOW)	$58,450 or below (LOW)	$93,450 or below (MOD)
Household Size: 6 People

	$37,450 or below (VLOW)	$62,450 or below (LOW)	$99,900 or below (MOD)
Household Size: 7 People

	$39,900 or below (VLOW)	$66,500 or below (LOW)	$106,350 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*
Permanent 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

	Gender	DOB	Ethnicity	Race	Disabled	In School
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Child 7

	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

Workshop Registration Form

About You

About Your Residence

About Your Income

About Your Family

Pre-Purchase & Financial Education Workshops

Pre-Purchase Workshop

Pre-Purchase Workbook

Pre-Purchase Workbook

Financial Education Workshop

Authorization to Obtain & Release Information

Privacy Policy

HUD Program Disclosure Form

Client & Counselor Roles & Responsibilities

Family Housing Advisory Services Program Disclosure

Household Data Survey

US Citizenship Attestation Form for Public Benefit

Client Assessment

Section 1: Financial Knowledge

Section 2: Financial Behavior

Section 3: Financial Challenges in the Last 6 Months

Financial Education - Pre-workshop Test

Homebuyer Pre-Test