NOTE: If you have an impairment, disability, language barrier, or otherwise require an alternative means of completing this form or assessing
information about housing counseling, please talk to your housing advisor about arranging alternative accommodations. We do business in accordance
with federal fair housing laws. It is illegal to discriminate against any person because of race, color, religion, sexual orientation, transgender, disability,
familial status, or national origin.

Equal Employment Opportunity and Affirmative Action Agency

 

Housing Channel

City of Fort Worth

 

CERTIFICATION OF INCOME STATEMENT

NOTE: Address, income amounts, and sources for ALL household members are required.

Certification: I certify that the information I am providing is true and could be subject to verification at any time by a third party. I also acknowledge that the provision of false information could leave me subject to the penalties of Federal, State, and Local law.

WARNING: TITLE 18, SECTION 1001 OF THE U.S. CODE STATES THAT A PERSON IS GUILTY OF A FELONY

FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OF THE UNITED STATES GOVERNMENT.

Check if Applicant refused to provide demographic information: Staff Assessment of Demographics:

NOTE: Address, income amounts, and sources for ALL household members are required.

Privacy Policy & Authorization

 

NOTE: If you have an impairment, disability, language barrier, or otherwise require an alternative means of completing this form or accessing information about housing counseling, please talk to your housing counselor about arranging alternative accommodations

Housing Channel is committed to assuring the privacy of individuals and/or families who have contacted us for assistance. We realize that the concerns you bring to us are highly personal in nature. We assure you that all personal information shared orally and/or in writing will be managed within ethical and legal considerations. Additionally, we want you to understand how we use the personal information we collect about you. Please carefully review this notice as it describes our policy regarding the collection and disclosure of your nonpublic, personal information.

What is nonpublic, personal information?

• Information that identifies an individual personally and is not otherwise publically available information, such as your Social Security Number or demographic data such as your race and ethnicity
• Includes personal financial information such as credit history, income, employment history, financial assets, bank account information and financial debts

What personal information does Housing Channel collect about you?

We collect personal information about you from the following sources:

• Information that you provide on applications, forms, email, or verbally
• Information about your transactions with us, our affiliates, or others
• Information we receive from your creditors or employment references
• Credit Reports

What categories of information do we disclose and to whom?  

We may disclose the following personal information to financial service providers (such as companies providing home mortgages), Federal, State, and nonprofit partners for program review, monitoring, auditing, research, and/or oversight purposes, and/or any other pre-authorized individual and/or organization. The types of information we disclose are as follows:

• Information you provide on applications/forms or other forms of communication. This information may include your name, address, Social Security Number, employer, occupation, account numbers, assets, expenses, and income.
• Information about your transactions with us, our affiliates, or others; such as your account balance, monthly payment, payment history, and method of payment.
• Information we receive from a consumer credit reporting agency; such as your credit bureau reports, your credit and payment history, your credit scores, and/or your creditworthiness.
• We do not sell or rent your personal information to any outside entity.
• We may share anonymous, aggregated case file information; but this information may not be disclosed in a manner that would personally identify you in any way. This is done in order to evaluate our program, gather valuable research information, and/or design future programs.
• We may also disclose personal information about you to third parties as permitted by law.

How is your personal information secured?

We restrict access to your nonpublic personal information Housing Channel employees who need to know that information in order to perform their housing counseling duties. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your nonpublic personal information; and we train our staff to safeguard client information and prevent unauthorized access, disclosure, or use.

(PRINT & SIGN)

RELEASE: I hereby authorize Housing Channel to release nonpublic personal information it obtains about me to my creditors and any third parties necessary to provide me with services I requested. I acknowledge that I have read and understand the above privacy practices and disclosures. 

(COMPLETE THIS SECTION ONLY IF OPTING OUT)

 

Opting Out of Certain Disclosures.

You may direct Housing Channel to not disclose your nonpublic personal information to third parties (other than disclosures made to project partners and those permitted by law However, if you choose to opt out, we will not be able to answer any questions from your creditors, which may limit Housing Channel’s ability to provide services such as foreclosure prevention counseling. If you choose to opt-out, please sign below under the “Opt-Out” clause. If you choose to release your information as stipulated in this Privacy Policy, sign under the “Release” clause. You may change your decision any time by contacting our agency.

 

 

OPT-OUT: I request that Housing Channel make no disclosures of my nonpublic personal information to third parties other than project partners and those permitted by law. By choosing this option, I understand that Housing Channel will NOT be able to answer any questions from my creditors. I understand that I may change my decision any time by contacting Housing Channel.

Disclosure Statement

 

NOTE: If you have an impairment, disability, language barrier, or otherwise require an alternative means of completing this form or assessing information about housing counseling, please talk to your housing counselor about arranging alternative accommodations.

About Us and Program Purpose: The mission of Housing Channel is to develop sustainable and affordable housing, revitalize neighborhoods and communities, and promote self-sufficiency through home ownership. Housing Channel is a nonprofit, HUD-approved housing counseling agency. We provide housing counseling and education services, including Pre-purchase Homebuyer Education Workshops, Non-Delinquency Post Purchase Workshops, Financial, Budgeting, and Credit Workshops, Mortgage Delinquency & Default Resolution Counseling, Financial Management/Budget Counseling, Pre-purchase Counseling, and Online Pre-purchase Homebuyer Education. 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 programs in conformity with local, state, and federal anti-discrimination laws, including the federal Fair Housing Act (42 USC 3600, et seq.). As a housing counseling program participant, please affirm your roles and responsibilities along with the following disclosures and initial, sign, and date the form on the following page.

 

Client and Counselor Roles and Responsibilities:

Counselor’s Roles & Responsibilities

• Reviewing your housing goal and your finances
• Preparing a Client Action Plan that lists the steps that you and your counselor will take in order to achieve your housing goal.
• Preparing a household budget.
• Your counselor is not responsible for achieving your housing goal, but will provide guidance and education in support of your goal.
• Neither your counselor nor agency employees, agents, nor directors may provide legal advice.

Client’s Roles & Responsibilities

• Completing the steps assigned to you in your Client Action Plan.
• Providing accurate information about your income, debts, expenses, credit, and employment.
• Attending meetings, returning calls, providing requested paperwork in a timely manner.
• Notify your counselor when changing housing goals.
• Attending educational workshops as recommended.
• Retaining an attorney if seeking legal advice and/or representation in matters such as foreclosure or bankruptcy protection

 

Agency Conduct: No Housing Channel employee, volunteer, or agent shall undertake any action that might result in, or create the appearance of, administering counseling operations for personal or private gain, provide preferential treatment for any person or organization, or engage in conduct that will compromise our agency’s compliance with federal regulations and our commitment to serving the best interests of our clients.

Agency Relationship: Housing Channel has financial affiliation with the US Department of Housing and Urban Development (HUD), US Treasury Department, Housing Partnership Network, Tarrant County Community Development, City of Fort Worth, City of Arlington, Wells Fargo, Bank of America, JP Morgan Chase, Legacy Texas Bank, Inwood National Bank, Frost Bank, Woodforest National Bank and Framework. As a housing counseling program participant, you are not obligated to use the products and services of Housing Channel or our industry partners. 

Alternative Services, Programs, and Products & Client Freedom of Choice: In the interest of full disclosure, Housing Channel also provides Down Payment Assistance Programs, Home Sales, and Rental Programs. As a housing counseling client, you are not obligated to participate in any of these services. You are entitled to choose whatever services and/or products best meet your needs.

Fee Structure: Housing Channel provides counseling services as listed above. No fees are charged to clients for counselingservices. Housing Channel offers online pre-purchase homebuyer education through our partnership with Framework at $75 per online course.

Referrals and Community Resources: You will be provided a community resource list which outlines regional services available to meet a variety of needs, including utility assistance, food banks, and legal aid assistance, among others. This list also identifies alternative agencies that provide services, programs, or products identical to those offered by the Housing Channel.

Errors and Omissions and Disclaimer of Liability: I/we agree that Housing Channel, its employees, agents, and directors are not liable for any claims and causes of actions arising from errors or omissions by such parties, or related to my participation in Housing Channel’s counseling; and I hereby release and waive all claims of action against Housing Channel and its affiliates. I have read this document, understand that I have given up substantial rights by signing it, and have signed it freely and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law. If any provision of this document is unenforceable, it shall be modified to the extent necessary to make the provision valid and binding, and the remainder of this document shall remain enforceable to the full extent allowed by law. Please note that representatives of Housing Channel do not provide tax or legal advice and that you should consult your tax advisor or attorney for such guidance.

Quality Assurance: In order to assess client satisfaction and in compliance with grant funding requirements, Housing Channel or one of its partners, may contact you during or after the completion of your housing counseling service. You may be requested to complete a survey asking you to evaluate your client experience. Your survey data may be confidentially shared with Housing Channel grantors such as HUD. By signing this Disclosure Statement, I give Housing Channel authorization to share my information with HUD and other third parties, as applicable.

I/we acknowledge that I/we received, reviewed, and agree to Housing Channel’s Program Disclosures.