Foreclosure Prevention Intake Form

If you are not a homeowner but would like assistance from FHANC, please complete this intake form instead. Thank you!

Please complete this form and a housing counselor will reach out to you
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
SMS Opt-In Disclosure: By providing a telephone number and submitting the form you are consenting to be contacted by SMS text message. Message & data rates may apply. Reply STOP to opt out of further messaging. View our privacy policy https://www.fairhousingnorcal.org/privacy-policy.html.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Current Address*
Street Address (include unit number)
City*
State*
5-Digit Zip Code*
County
What is your race?*
What is your ethnicity?*

LatinxNot LatinxChose not to respond
What is your gender?*
What is your preferred language?*
Are you behind on or struggling to pay your gas or electric bill? Would you like to know about PG&E’s low income energy assistance and medical assistance programs?*

YesNo

Household Members Breakdown

Including yourself, please enter the number of people in your household by category
Number of adult females (18+)
Number of adult males (18+)
Number of minors (under 18)
Total Household Size (auto-calculated)
Is anyone in your household age 62 or older?

YesNo
Does anyone in your household have a mental or physical disability?

YesNo
Disability Type

PhysicalMentalBoth, physical and mental

Household Members Breakdown