This is an initial intake form. Some services may require additional fees and/or documents. Please select all services you are interested in:
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NeighborImpact 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 both orally and/or in writing will be managed within legal and ethical considerations. Please carefully review this notice as it describes our policy regarding the collection and disclosure of your nonpublic, personal information. Your “nonpublic personal information” (information that identifies you personally and that is not otherwise publically available information) such as your total debt information, income, living expenses and personal information concerning your financial circumstances, will be provided to creditors, program monitors, and others only with your authorization and signature. We may also use anonymous aggregated case file information for the purpose of evaluating our services, gathering valuable research information and designing future programs. NeighborImpact has a client complaint policy and you can request a copy of it at any time from our agency or you can download it from our website www.neighborimpact.org.
TYPES OF INFORMATION WE GATHER ABOUT YOU
YOU MAY OPT-OUT OF CERTAIN DISCLOSURES
RELEASE OF YOUR INFORMATION TO THIRD PARTIES
I hereby authorize the release/exchange of my information to and from NeighborImpact in order to assist with my case.
I authorize NeighborImpact to:
I understand that this information will be released only to those institutions, companies and agencies that NeighborImpact reasonably believes can provide assistance, or to agencies which support the operations and mission of NeighborImpact, including HUD, City of Bend, City of Redmond (CDBG funds) and NeighborWorks America. Examples of other such entities include mortgage servicers, mortgage investors, public agencies and nonprofit organizations.
I understand that the provision of services at NeighborImpact is not contingent on my signing this authorization form.
This consent is voluntary and shall remain in effect until it is revoked or NeighborImpact’s services are complete. I further acknowledge that I may revoke this consent in writing at any time except to the extent that action based on this consent has already been taken.
I acknowledge that a copy or electronic reproduction of this form is as valid as the original.
Questions? Call: (541)323-6567 between the hours of 8:30am and 4:30pm Mon-Fri or e-mail: firstname.lastname@example.org
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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.
NeighborImpact and Program Purposes: NeighborImpact is a nonprofit, HUD approved comprehensive community action agency. The HomeSource Department offers counseling and education on credit/budget management, pre-purchase, reverse mortgages, loss mitigation, individual development accounts, homebuyer education/counseling, post-purchase and financial fitness. NeighborImpact Weatherization program offers home rehabilitation services, NeighborImpact Lending department offers a series of loan products including down payment assistance and preservation loans. 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 and Responsibilities
Client’s Roles and Responsibilities
Agency Conduct: No NeighborImpact employee, officer, director, contractor, 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 Relationships: NeighborImpact has financial affiliations with HUD, NeighborWorks America, E-Home America, and FrameWork. NeighborImpact also has received donations from Umpqua Bank, JP Morgan Chase & Co, Bank of America Charitable Foundation Inc. – California, Neighborhood Reinvestment Corp. (Sun Trust Bank), Washington Federal Foundation and Wells Fargo Foundation. As a housing counseling program participant, you are not obligated to use the products and services of NeighborImpact or our industry partners.
Alternative Services, Programs, and Products & Client Freedom of Choice: NeighborImpact lending department offers first-time homebuyer down payment assistance. However, you are not obligated to participate in this or other NeighborImpact programs and services while you are receiving housing counseling from our agency. You may consider seeking alternative products and services, including those offered by the Federal Housing Administration (FHA), Oregon State first-time homebuyer loan programs, United States Department of Agriculture (USDA) loans. A list of community resources is provided during your initial intake session and/or available anytime with our receptionist. You are entitled to choose any real estate professionals, lenders, and lending products that best meet your needs.
Referrals and Community Resources: You will be provided a community resource list which outlines many county and regional services available to meet a variety of needs related to your housing and financial fitness. You may also be referred to other housing services of the organization or another agency or agencies as appropriate that may be able to assist you with particular concerns that have been identified. This list identifies alternative agencies that provide services, programs or products identical to those offered by NeighborImpact and its industry partners. You understand that you are not obligated to use any of the services offered to you.
Errors and Omissions and Disclaimer of Liability: I/we agree NeighborImpact, its employees, agents, and directors are not liable for any claims and causes of action arising from errors or omissions by such parties, or related to my participation in NeighborImpact counseling; and I hereby release and waive all claims of action against NeighborImpact 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.
Quality Assurance: In order to assess client satisfaction and in compliance with grant funding requirements, NeighborImpact, or one of its partners, may contact you during or after the completion of your housing counseling service. You may be asked to complete a survey asking you to evaluate your client experience. Your survey data may be confidentially shared with NeighborImpact grantors such as HUD or NeighborWorks America.
I acknowledge that I received, reviewed and agree to NeighborImpact’s Program Disclosures.
I/We understand that any intentional or negligent representation(s) of the information contained on this form may result in civil liability and/or criminal liability under the provisions of Title 18, United States Code, Section 1001.