Post-Purchase Counseling Intake Form

Post-Purchase Counseling Intake Form
Why would you like Housing Counseling?*
Ex: I am interested in NeighborWorks Sacramento's Fix & Flourish Loan Program, I purchased a home and want to know more about being a home owner, I purchased a home and need help budgeting my new expenses, etc
Applicant Information

Tell us about yourself!
Applicant Name*

First NameMiddle NameLast Name
Applicant Date of Birth*

MonthDayYear
Date
Applicant Gender*
Applicant Race*
Applicant Ethnicity*
Applicant Primary Language Spoken*
Contact Information
Phone Number*
Please enter a valid phone number.
Applicant Email*
example@example.com
Address*

Street Address

apt #

CityState

Zip Code
What county do you live in?*
County
What is your rural area status?*
Please answer the following questions so we can better serve you.

All information provided will be kept private and confidential in accordance with our policy.
Were you a first time homebuyer?*

TrueFalse
Are you the Head of Household?*

TrueFalse
Are you a single parent?*

TrueFalse
What is your Marital Status?*
Are you foreign born?*
Highest Level of Education*
Are you disabled?*
Do you have a disabled dependent?*
Are you a Veteran?*
Are you Active Military?*

Monthly Spending Worksheet

Please enter your monthly average spending amount per category. If a category does not apply to you, please input the number zero (0).

Monthly Debt Payments
Credit Card Payment 1*
Student Loan Payment*
Credit Card Payment 2*
Medical Debt Payment*
Credit Card Payment 3*
Child Support Payment*
Credit Card Payment 4*
Other Debt Payment*

Housing
Mortgage Payment*
Principal, Interest, Taxes, and Insurance*
Electric Bill*
Water/Sewer/Garbage*
Gas Bill*
Other Housing Expense*

Transportation
Vehicle Payment 1*
Vehicle Insurance*
Vehicle Payment 2*
Vehicle Maintenance*
Gas/Fuel*
Other Transportation Expense*

Personal Care
Groceries*
Gym / Health Club*
Dining Out / Take Out*
Toiletries*
Clothing*
Other Personal Expense*

Entertainment
Cell Phone*
Music Subscriptions*
Internet / WiFi*
TV / Movie Subscriptions*
TV / Cable*
Other Entertainment Expense*

Other Expenses
Child Care*
Medications*
Child School Tuition*
Donations*
Other Child Expenses*
Gifts*
Pet Expenses*
Other Expense*

Savings & Investments
Retirement Account*
College Fund*
Investment Account*
Monthly Savings Deposits*
Other Savings/Investments*

Housing Counseling Disclosure

Please read the disclosure in it's entirety.
Services Offered:
NeighborWorks® HomeOwnership Center Sacramento Region offers the following HUD one-on-one counseling and group education services: Pre-Purchase Counseling, Foreclosure Prevention Counseling, Rental Counseling, Non-Delinquent Post-Purchase Counseling, Preparing for HomeOwnership Workshops, and Financial Capability Classes. See the first Addendum, “HomeOwnership Center Services,” for a full description of our services.

Privacy Statement:
NeighborWorks® HomeOwnership Center Sacramento Region values your privacy. When you use our service, we collect personal information in order to provide the services you requested and to support our housing counseling program. We collect the following information: information we receive from your application and other forms, information about your transactions with us, our affiliates, or others, and information we receive from a consumer reporting agency. Our agency takes precautions to keep your information confidential and secure per HUD requirements. NeighborWorks® HomeOwnership Center Sacramento Region may not use or disclose the information provided by you without written consent except under the following circumstances: as necessary to provide the services you request, as required by law or in response to a subpoena or search warrant, or to outside auditors such as HUD or NeighborWorks® America who have agreed to keep the information confidential.

Relationships with Industry Partners:
NeighborWorks® HomeOwnership Center has financial relationships with several partners in the industries of lending, real estate, insurance, and other related fields. See the Addendum “Financial Partnerships” for a list of partnering organizations.

No Client Obligation:
There is no obligation to receive, purchase, or use any product or service offered by this agency or any services of its industry partners or another party in exchange for your receiving HUD housing counseling and/or education services.

Alternatives:
As a condition of our services and in compliance with HUD’s Housing Counseling Program requirements, we may provide information on alternative services, programs, and products available to you.
Acknowledgments
Please initial that you have read and understand the following acknowledgments:

1. I understand that NeighborWorks Sacramento provides housing counseling. A written action plan will be provided consisting of recommendations for handling my situation, possibly including referrals to other housing agencies as appropriate.

2. I understand that a credit report is required for NeighborWorks Sacramento to provide the best assessment for customers. I agree to provide my report following the Credit Report Authorization agreement.

3. I understand that NeighborWorks Sacramento receives Congressional funds for housing counseling. As such, it is required to submit client-level information through the online reporting system with program administrators or their agents for program monitoring, compliance, and evaluation.

4. I may be referred to other housing services or agencies as appropriate to able to assist with concerns that have been identified. I understand that I am not obligated to use any of the services offered to me.

5. I can “opt-out” of disclosures of my non-public personal information to third parties (such as your creditors).

By intialing below I chose to opt-out of disclosures of my non-public personal information to third parites (such as your creditors)
Applicant Initials
Co-Applicant Initials
If I choose to “opt-out,” NeighborWorks Sacramento will not be able to answer questions from my creditors. If at any time, I wish to change my decision regarding my “opt-out” choice, I may call 916-452-5356 and do so.

Third-Party Release Information

1. So long as you have not opted out, NeighborWorks Sacramento may disclose some or all of the information that we collect, as described above, to creditors, where we have determined that it would be helpful to you, would aid us in counseling you, or is a requirement for grant awards.

2. We may also disclose any nonpublic personal information about you as permitted by law (e.g., if we are compelled by legal process).

3. Within the organization, we restrict access to nonpublic personal information about you to those employees who need to know that information to provide services to you. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your nonpublic personal information.

I acknowledge the above and have received a copy of NeighborWorks Sacramento’s privacy policy.
Applicant Name*

First NameLast Name
Applicant Signature*

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Date Signed

MonthDayYear
Date
Co-Applicant Name

First NameLast Name
Co-Applicant Signature

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Date Signed

MonthDayYear
Date

Credit Report Authorization

Please read this authorization form in its entirety.
A credit report is required for NeighborWorks® HomeOwnership Center Sacramento Region to review customers’ credit files for housing counseling purposes. You may choose to provide your own credit report or allow NeighborWorks® HomeOwnership Center Sacramento Region to pull one for you. Please read the following acknowledgments and choose how you would like to submit your credit report.
Please confirm how NeighborWorks Sacramento will receive your Credit Report*
By checking the box below, I authorize the following

I understand that NeighborWorks Sacramento to pull my credit report. I understand that NeighborWorks Sacramento will use CoreLogic Credco to pull my report. I agree to pay $29.60 per person, per report, at the time of my housing counseling appointment. I understand that if I am facing foreclosure or am homeless, I will not have to pay this fee. Upon customer request, CoreLogic Credco will mail a copy of the credit report to me. I understand that for NeighborWorks Sacramento to pull my credit report, I will need to provide a copy of my photo ID and social security number prior to my housing counseling appointment.
Applicant Name*

First NameLast Name
Social Security Number*
Applicant Signature*

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Date Signed

MonthDayYear
Date
Co-applicant Credit Report Authorization

If you have a Co-applicant, Please have them read this authorization form in its entirety.

Do you have a Co-Applicant? If yes, please fill this section out
A credit report is required for NeighborWorks® HomeOwnership Center Sacramento Region to review customers’ credit files for housing counseling purposes. You may choose to provide your own credit report or allow NeighborWorks® HomeOwnership Center Sacramento Region to pull one for you. Please read the following acknowledgments and choose how you would like to submit your credit report.
Please confirm how NeighborWorks Sacramento will receive your Credit Report
If you selected "I authorized NWS to pull my credit report" above, please confirm that you understand the following by checking the box

I understand that NeighborWorks Sacramento to pull my credit report. I understand that NeighborWorks Sacramento will use CoreLogic Credco to pull my report. I agree to pay $29.60 per person, per report, at the time of my housing counseling appointment. I understand that if I am facing foreclosure or am homeless, I will not have to pay this fee. Upon customer request, CoreLogic Credco will mail a copy of the credit report to me. I understand that for NeighborWorks Sacramento to pull my credit report, I will need to provide a copy of my photo ID and social security number prior to my housing counseling appointment.
Co-applicant Name

First NameLast Name
Social Security Number
Co-applicant Signature

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Date Signed

MonthDayYear
Date

Additional Disclosures and Disclaimers

The following document are for your reference only. No signatures or submissions are required.

Post-Purchase Counseling Intake Form

Applicant Information

Contact Information

Please answer the following questions so we can better serve you.

Income

Monthly Spending Worksheet

Housing Counseling Disclosure

Credit Report Authorization

Co-applicant Credit Report Authorization

Additional Disclosures and Disclaimers

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