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Housing Appointment Request (Solicitud de cita)
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Name (Nombre)
*
Name/ Nombre
Last Name/ Apellido
Phone Number (Número de teléfono)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address (Correo electrónico)
example@example.com
Required Services (Servicios requeridos)
*
Please Select
Buy a home/ Comprar una Casa
Late on Mortgage/ Retrazo en Hipoteca
Rental counseling/ Consejeria de renta
Late on Rent/ Tarde en Renta
Benephilly/ Public Services- Aplicacion para servicios publicos
Other/ otro
How many months are you behind on rent? (Cuántos meses de alquiler debe?)
*
Do you have an eviction notice? (Tiene una notificación de desalojo?)
*
Yes/Sí
No
How many months are you behind on the mortgage? (Cuántos meses de atraso lleva en la hipoteca?)
Do you have a realtor or lender? (Tiene agente inmobiliario o prestamista?)
*
Yes/Sí
No
What Benefits do you need to apply for? (Para qué beneficios necesita solicitar?)
Please Select
SNAP (food stamps)
LIHEAP
CAP - Help with energy bill
CRP - Help with the gas
TAP - Help with Water
TANF - Help for dependent children
Senior Real Estate Tax Freeze
Property Tax Rebate (PRT)
Homestead
Basic Repair System- free repairs for owner occupied homes
Medicaid- Health benefits
CHIP
WIC
Other
Do you require translation services? (Necesita servicios de traducción?)
*
Please Select
English
Spanish/Español
Other
If other, please specify language (Si es otro idioma, por favor especifique cuál.)
Do you have court? (¿Tienes una cita en la corte?)
*
Yes/ Sí
No
Have you received Act 91 from lender? (Ha recibido el aviso del Acto 91 por parte del prestamista?)
*
Yes/ Sí
No
Don't Know / No Sé
Request Appointment
Should be Empty: