We will verify certain information, pull your credit report (soft pull), and complete a financial assessment and an action plan. Please complete this form, read the information provided, and sign and date where indicated. *In addition to your information and signatures, IF you haven't already provided the following for each adult/applicant should provide a copy of the last 2 paystubs, your last bank statement, and pay a credit check fee.

* You may pay with cash, money order, cashier's check, PayPal, or credit card (+ an electronic processing fee)

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I/We authorize Clinch-Powell RC & D Council, Inc. to check any and all information and/or references contained herein, including but not limited to creditors, employers, and landlords. Clinch-Powell may also ask to see and/or photocopy my Driver's License, Identification Card, and/or Social Security Card for the purpose of confirming my identification or as specific programs require. I authorize Clinch-Powell to use my Social Security, or other federally issued identification number for the purpose of obtaining my credit report for the purpose of evaluating my credit history. I also authorize the release of my credit report to Clinch-Powell by those credit reporting agencies from which Clinch-Powell may request my credit report. *To assist Clinch-Powell in its ability to provide me with financial counseling services, I hereby authorize Clinch-Powell to pull my Transunion credit report and FICO score now and periodically, but not more frequently than once every six (6) months for a period not to Clinch-Powell exceed five (5) years from the date of this authorization. I understand that all inquiries by into my credit constitute "soft inquiries" and will not adversely affect my credit or my credit rating. While the credit reports and scores pulled by Clinch-Powellonmy behalf will be used to provide me with financial counseling and/or to track my financial outcomes, it is understood that I will not receivea copy of the credit reports. I understand that I may request a financial counseling session at Clinch-Powell in the future to discuss information in any credit report and/or credit score pulled by Clinch-Powell on my behalf. I further understand that I may withdraw Clinch-Powell's authorization to pull additional credit reports or credit scores at any time without penalty. Notwithstanding the foregoing, I understand that I have the right to dispute information with the credit bureau, to request reinvestigation, and to have corrected reports reissued to previous recipients of the credit report at issue. I understand that credit information is sensitive and that there may be inherent risks to accessing such data; I have had the opportunity to ask my Financial Coach questions regarding such risks. I understand that all of my personal information will be held confidential by Clinch-Powell and used only as authorized by me. I understand that the purpose of this intake packet is to permit Clinch-Powell to assess my current situation and help me determine strategies for reaching my economic goals. I understand the role of Clinch-Powell/Financial Coach is to advise assist me in determining my options and potentially applying for options, but not necessarily complete all tasks on my behalf. Clinch-Powell has no control over the outcomes as it relates to outside parties. In the event that I could also be served through multiple Clinch-Powell programs, I authorize the transfer of this intake packet and the information contained within to another Clinch-Powell program. At the time of file transfer, I will be given the opportunity to discontinue services if I so choose. There may be fees associated with the services that Clinch-Powell provides to me, but I will be advised of such a fee in advance of service. If I provide specific account information for electronic payment, I authorize Clinch-Powell to utilize it for my expressed purposes (provided by me either written or verbally I understand checks must clear before payment will be credited, there is $30 fee for insufficient funds, and that any money previously owed to Clinch-Powell must be reconciled before new services may begin. If a fee will cause me significant hardship, I am encouraged to request a waiver. I/we hereby authorize Clinch-Powell, when appropriate, to share information with the Department of HUD, LISC, Fahe, THDA, or another relevant third party, partnering agency or funder for the purposes of program monitoring, reporting, compliance, evaluation, and/or research. This information will not be disclosed or sold to outside, unrelated third parties without my knowledge. I authorize Clinch-Powell to contact me by any method I have provided. I understand Clinch-Powell has no control over the security of communication methods outside of its internally owned communication portals, and is not responsible for external security breaches. By signing below, I/we are verifying that I/we have read and understand the terms set forth within this authorization, as well as, have been explained and/or read the Consent Form for Research, and the disclosures and privacy policy that accompany this authorization. Iunderstand that this form is an authorization to collect specific information and assess my situation. This authorization will expire five (5) years from the dates below.

Clinch-Powell RC&D Council is a non-profit Community Housing Development Organization and a HUD-approved counseling agency (82394) that, among other activities, helps families with affordable housing goals. Most services are available in alternative formats and locations upon request. Clinch-Powell receives funding for its housing programs through grants and loans from a number of sources, including but not limited to: USDA Rural Development, US Dept. of Housing & Urban Development [HUD], Corporation for National and Community Service, Federal Home Loan Bank, the Environmental Protection Agency, State of TN, THDA, Fahe/ Just Choice Lending, Citizens Bank & Trust Co. of Grainger County, Rural LISC, Fannie Mae, Freddie Mac, TVA, Ballad Health, East TN Foundation, United Way, public fundraising, and private donations. As a housing counseling agency, Clinch-Powell offers the following services: 1) Pre-Purchase Homebuyer Education Workshops-- utilizingthe Realizing the American Dream curriculum; 2) Pre-Purchase Counseling-financial readiness to purchase/own an affordable home; 3) Post- Purchase Counseling and Vorkshops--non-delinquency home improvement, energy efficiency; 4) Foreclosure Prevention/Loss Mitigation Counseling-assisting to resolve mortgage defaults; 5) Rental Counseling--locating safe/decent rental housing; 6) Household Budgeting & Credit Repair Counseling and Workshops--financia literacy and personal money management; 7) High-Cost Mortgage Counseling-requirement of certain mortgage loans to ensure borrower's understanding of the risk of the loan. Clinch-Powell, along with Clinch-Powell Construction Company develops affordable single-family homes to sell to low- to moderate- income families. In addition to coordinating the packaging and servicing of select loan products, subsidiary, TaCL, and Clinch-Powell itself occasionally offers low-interest loans and grants for various affordable housing activities. Clinch-Powell NMLS #195063; S. Karge NMLS#2403630. Please visit http://mortgage.nationwidelicensingsystem.org/to find more information regarding history and profile as a mortgage lender. Lastly, Clinch-Powell is a property manager for multiple duplexes and single-family rental housing units which it also owns. In providing counseling services, Clinch-Powell housing counselors will present to their clients several options in the furtherance of their housing goal/service, possibly including recommendations of some of the above listed services. The Clinch-Powell housing counselorwill recommend only services that are in the best interest of the client, and will inform the client of any interests the organization has in any particular product or service. Within the agency, individual housing counselors may perform multiple affordable housing activities within the scope of their regular job duties, and as such, will not receive any additional funds or incentives specifically for those activities. Moreover, as per HUD guidelines, housing counselors will not simultaneously participate in specific housing activities. As the client, you have the right to inquire as to specific relationships Clinch-Powell or its employees have with other entities. You also have the right to choose (or not) the products or services that you feel are right for your household, regardless of any option presented or recommendation made by the housing counselor. YOU ARE UNDER NO OBLIGATION TO UTILIZE/RECEIVE, OR EVEN CONTINUEWITH SERVICES THROUGH YOUR HOUSING COUNSELOR OR CLINCH-POWELL AS A WHOLE. Your decision to utilize or not utilize certain programs and products will not in any way affect your housing counseling service. If you decide to discontinue services with Clinch-Powell, or if your need is beyond the scope of the agency's capabilities, Clinch-Powell staff will assist you locating a more suitable local agency. If you/your housing situation meet certain criteria, we may collect personal information directly from you and enter into a computer system call HMIS (Homeless Management Information System Many agencies that provide assistance use this computer system to gather information about clients that are homeless or at risk of homelessness. We only collect information that we consider to be appropriate. You are not required to provide this information. However, without your information we may not be able to fully assist your needs. All information provided to the HMIS system is safeguarded and held under tightest security. Clinch-Powell is an equal opportunity provider, employer, and lender. Discrimination is prohibited by Federal law. Clinch-Powell Resource Conservation and Development Council is a 501(c)(3) non-profit organization. All programs of the RC&D are available without regard to race, color, national origin, religion, sex, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, reprisal or retaliation for prior civil rights activity, in any program or activity conducted, or because the applicant has in good faith exercised any right under the Consumer Credit Protection act. The federal agencies that administer compliance with these laws are: U.S. Department of Justice, Civil Rights Division, 950 Pennsylvania Avenue, NW Washington, D.C. 20530-000; Federal Trade Commission, 600 Pennsylvania Avenue, NW, Washington, D.C.

We may collect non-public personal information about you from the following sources: A) Information that you provide to us orally or written, such as on applications or other forms; B) Information about your transaction with us or others; and C) Information from others, such as credit bureaus, real estate appraisers, lenders and employers. We do not disclose any non-public personal information about you without your consent to anyone, except: information provided to your lender as required to gain approval for a loan or protect your current home, to government agencies and grantors in compliance with their respective monitoring and reporting requirements, in broader forms to partnering agencies for reporting purposes, joint applications, and/or compilation of statistical data, as required by law. To maintain security of customer information, we restrict access to your personal and account information to persons who need to know that information in order to provide you products and services requested with this application. We may disclose certain limited information to relevant third parties as part of a particular service as further described in the specific program authorization. We maintain physical, electronic and procedural safeguards that comply with federal standards to guard your non-public personal information. As a client, you have the right to opt-out and direct us to withhold non-public personal information from third parties, or to specify/limit to whom such information is provided. If you choose to opt-out, we will not be able to answer questions from third parties. To opt-out, you will need to make special note of this on this page, written separately, or explicitly stated to your counselor; not signing this page is not sufficient to opt-out. If at any time, you wish to change your decision with regard to your opt-out, you may call us at 865-828-5927 and do so. If you decide to discontinue services through Clinch-Powell, we will still adhere to the policies and practices as described in this notice. The agency will continue to safely maintain your records for a period of time, of up to three (3) years, after which all digital files will be purged and paper documents will be shredded and destroyed.

I have been provided a copy of, fully read, and understand the information within this disclosure, as well as, Clinch- Powell RC & D's policies regarding conflicts of interest and the confidentiality of client information as state above.

Clinch-Powell is an equal opportunity provider, employer, and lender. Discrimination is prohibited by Federal law. Clinch-Powell Resource Conservation and Development Council is a 501(c)(3) non-profit organization. All programs of the RC&D are available without regard to race, color, national origin, religion, sex, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, reprisal or retaliation for prior civil rights activity, in any program or activity conducted, or because the applicant has in good faith exercised any right under the Consumer Credit Protection act. The federal agencies that administer compliance with these laws are: U.S. Department of Justice, Civil Rights Division, 950 Pennsylvania Avenue, NW Washington, D.C. 20530-000; Federal Trade Commission, 600 Pennsylvania Avenue, NW, Washington, D.C.NMLS# 195063 / S.Karge NMLS# 2403630