Homeownership Center Intake Form

Homeownership Center Intake Form
Primary Applicant Information
Who referred you*
If a company (such as Realtor or Lender), please specify.
If a company referred you (such as Realtor or Lender), please specify who.
Name of Primary Applicant*

First NameLast NameSuffix
Social Security Number*
Date of Birth*

MonthDayYear
Gender*
Marital Status*
Highest Level of Education*
Household Type or Tax Filing Status*
Military Status*
Veteran Status*
Are you a resident of an Indian reservation?*

YesNo
Do you currently receive income?*

YesNo
Primary Applicant Contact Information
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email of Primary Applicant*
example@example.com
Phone Numbers*
Preferred Contact Method*
Primary Applicant Other Information
Preferred Language*
Is English your second language*

YesNo
Number of people living in the home*
Number of dependents*
Living Status*
Disabled?*
Race*
Ethnicity*
Are you a first time homebuyer?
A First time homebuyer applies to anyone who has not owned a home in the past 3 years.
Primary Applicant Employment
Employment Status*
Employer Name*
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number*
Please enter a valid phone number.
Date you started at this job*

MonthDayYear
Date
How often do you receive a paycheck?*
Monthly Gross (before taxes) Amount:*
Monthly Net (after taxes) Amount:*
Is there a secondary applicant besides you?*

YesNo

Secondary Applicant Information
Name of Secondary Applicant*

First NameLast NameSuffix
Social Security Number*
Date of Birth*

MonthDayYear
Gender*
Marital Status*
Highest Level of Education*
Military Status*
Veteran Status*
Does the secondary applicant currently receive income?*

YesNo
Secondary Applicant Contact Information
Does the Secondary Applicant have the same address as the Primary Applicant?*

YesNo
Household Type or Tax Filing Status*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email of Secondary Applicant*
example@example.com
Phone Numbers*
Preferred Contact Method*
Secondary Applicant Other Information
Disabled?*
Race*
Ethnicity*
Is the Secondary Applicant a resident of an Indian reservation?*

YesNo
secondary applicant Veteran Status*
Secondary Applicant Employment
Employment Status*
Employer Name*
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number*
Please enter a valid phone number.
Date you started at this job*

MonthDayYear
Date
How often do you receive a paycheck?*
Monthly Gross (before taxes) Amount:*
Monthly Net (after taxes) Amount:*

Financials
Total Annual Income for the entire household*
If you have a spouse or domestic partner who is not applying still include their income. We use total household income to evaluate you for grant and other program eligibility
Income*
Expenses*
Assets*

Document Check List

Please provide the documents as they apply to you and upload as PDF documents. These documents will assist our counselors to better assist you in reaching your financial goals. If you are missing any of these documents please just upload a blank document. If you have any questions, please contact our office at 570-558-2490.
30 day proof of income for all household members*

(Pay Stubs)
Cancelof
30 Day recent bank statement*

All Accounts
Cancelof
Driver's License or State ID*

Cancelof
Most Recent Tax Return and/or W-2*

Cancelof
Mortgage Statement*

Cancelof
Proof of Delinquent Loan/Lien

Cancelof
Loan Estimate

Cancelof
Benefit Award Letters

(SSI, SSD, Public Assistance)
Cancelof
Sales Agreement

Cancelof
Inspection Report

Cancelof
Statements for Any Investments

(Retirement, Stocks, Etc.)
Cancelof
Copy of Property Deed

Cancelof
Utility Bills

Cancelof
Homeowner's Insurance Policy

Cancelof
I have read and acknowledge that I have reviewed the above requested documents list.*

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Primary Applicant Information