IAH Client Intake Form

IAH Client Intake Form

Thank you for allowing In Affordable Housing, Inc. to work with you on your housing needs. As a HUD certified counseling agency, we collect select information. The demographic questions are voluntary and tgwill not affect your eligibility for services. Complete all required field and submit. If contacting IAH for Foreclosure Prevention Services, note that we do nor offer financial assistance or take mortgage payments. For questions, contact: info@inaffordablehousingar.org or 501-221-2203.
Reason for Visit
What brings you to IAH?

Other
Please describe other reason
Your Information
Full Name

First NameMiddle InitialLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Street Address, City, State, ZIP

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
County
Household
Number of people in household
Number of children under 18
Household type
Household characteristics
Household Income
Total Annual Household Income (Gross from All Sources)
Number of Income Earners
Language
English language ability
Primary language spoken at home
Housing Goal
Your primary housing goal in the next 6–12 months
How did you hear about IAH?

Other
Authorization (Foreclosure Prevention Only)
Permission to contact mortgage company
Required Acknowledgment
Permission to Follow Up by phone, email, or text
Certification and Signature
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
File Upload-Foreclosure Prevention

Please upload any recent letters from your mortgage company.
File Upload

Cancelof
Should be Empty:

IAH Client Intake Form

Reason for Visit

Your Information

Household

Household Income

Language

Housing Goal

Authorization (Foreclosure Prevention Only)

Required Acknowledgment

Certification and Signature

File Upload-Foreclosure Prevention