PREPURCHASE HOME BUYERS WORKSHOP INTAKE FORM

PREPURCHASE WORKSHOP INTAKE FORM
Please provide all the requested information clearly and completely to ensure your application is processed correctly. The information collected on this form is used exclusively by MHAGH and will not be shared with any other organization. If you have any questions about this form or how we will use your information, please contact us at 860-904-6866 or email us at education@mutualhousing.org

TO JOIN, PLEASE ANSWER ALL QUESTIONS.
PARTICIPANT INFORMATION
Full Name*
Full address including unit number*
City*
State*
Zip Code*
Phone Number*
Email*
example@example.com
DEMOGRAPHIC INFORMATION
Household Information
Gender*

FemaleMaleOther
Ethnicity*

HispanicNot HispanicChoose not to respond
Race*

American Indian/ Alaska NativeBlack/ African AmericanNative Hawaiian/ Pacific IslanderWhiteAsianMore than One raceChoose not to respond
Date of Birth*

MonthDayYear
Date
HOUSEHOLD INFORMATION
Are you the head of household?*

YesNo
Household Size?*
Number of dependents?*
Marital Status: *
Type of household?*

Married with childrenMarried without childrenDomestic PartnershipTwo or more Unrelated AdultsMale-Head Single parentFemale-Head Single parentSingleOther
Highest level of Education?*

UnknownElementaryHigh SchoolJunior CollegeUniversityGraduate School (M.S, M.B.A or P.H.D)
Gross Monthly Income*
Preferred Language*
Are you fluent in English?*

YesNo
First time Homebuyer (don't own any property/not on title)*

YesNo
First generation Homebuyer?*

YesNo
Do you live in a rural area?*

YesNo
Are you purchasing in CT?*

YesNo
How did you hear about us?*

RadioEmployerTVBankFriendOnlineOther
Would you like to receive information about MHAGH events?*

YesNo
Initial by each section to confirm that you received the following documents:*
DISCLOSURE: MHAGH is nonprofit, HUD-approved, comprehensive housing counseling agency. We serve all clients regardless of income, race, color, religion/ creed, sex, national origin, age, family status, disability, or sexual orientation/gender identity. We administer our program in conformity with local, state, and federal anti-discrimination laws. As a housing counseling program participant, you are not obligated to use the product and services of MHAGH or our industry partners.
Signature*

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Date*

MonthDayYear
Date
Initial each section to confirm that you received the following documents:

For your protection: 1. Get a home inspection (HUD 92564-CN/ HUD (HUD 92564-CN/ HUD- Spanish) / 2. Ten important questions to ask your home inspector / 3. Disclosure of Lead-based Paint Hazard in Housing (EPA-747-F-96-002) / 4. Privacy disclosure.
Select the date of the workshop you’d like to attend.*
Please note that this is a tentative selection and may be changed at a later time.
Should be Empty:

PREPURCHASE WORKSHOP INTAKE FORM

PARTICIPANT INFORMATION

DEMOGRAPHIC INFORMATION

Household Information

HOUSEHOLD INFORMATION

Initial each section to confirm that you received the following documents: