AGORA Community Services Client Intake

CORONAVIRUS == We are In this Together!!!

We invite you to share these services with Friends, Family and Neighbors. Below, you will have an opportuity to: (1) Select the Home Owner or Home Buyer, Rental and Reverse Mortgage OUTREACH EVENT to stay up-to-date, ask questions to ensure housing retention after the CRISIS has subsided. (2) Understand your next steps and Options such as Modification vs Forbearance, etc.

All information is transmitted directly to AGORA securely and held in strict privacy for your protetion. Your information is not shared with anyone.

We thank you for staying informed so that we can continue to help in decreasing loss of housing by community residents.
Select the OUTREACH EVENT you would like to attend to begin your Counseling Services, Current Clients: Select 1 or more Outreach Sessions to STAY UP-TO-DATE *

HOME OWNERS "Keep Your Home_CRISIS BUDGET" Nest Available Saturday 10:00 AM HOME BUYERS "Get Ready- Get Set - To Buy Your Home" Next Available Saturday 11:45 PM Renters are invited to any of the above, as we cover ALL CoronaVirus information affecting us all.
1.Date *

Month Day Year
2. SERVICE TYPE: *
CLICK ARROW & SELECT SERVICE TYPE
I understand that if I receive Rental/Homeless Prevention Services and obtain a Referral Resource, I Agree to continue Housing Advising Sessions for 90 Days after Resource Approval.
3.Full Name *

First Name Middle Name Last Name
4.Co- Borrower on Loan?
Enter N/A or the Co-Borrower's Name as show on the Mortgage
5.Co-Borrower Relationship
Enter N/A or Name of Spouse , etc.
6.Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
7.Marital Status *
8.Social Security # *
or TIN #
9.Birth Date *

Month Day Year
10.Phone Number *
11.Phone Type *
12.Gender *

Male Female Other
13.E-mail
16.Ethnicity *

Hispanic Non-Hispanic
14.Can We Text Appt. Reminders/Updates?
15.Phone Number
17.Race *

Am Indian /Alaskan Native Am Indian / Alaskan Native and Black Am Indian/ Alaskan Native White Asian Asian and White Black or African American Black or African American and White White Native Hawaiian or Other Pacific Islander Hispanic Choose not to respond
18.Education *
19.Language *

English Spanish Other
20. Limited English Proficiency *
21. Employment *
22. Live in Rural Area *
23. Serving or Served in Arm Services? *
24. Have you Filed Bankruptcy? Are you considering it?
25. Type of Bankruptcy file and year *
Chapter 13 OR Chapter 7 or N/A
26. Discharged or Dismissed *
Type Discharged if you finished Chapter 7 or 13 ; Type Dismissed if you did not finish Chapter 13. OR N/A
27. Household Annual Gross Income *

Less than $25,000 $25,500 - $41,500 $41,600 - $61,500 Over $61,000
28. Head of Household? *
29. Number in Household? *

1 2 3 4
30. HOUSING THE STORY - HOME OWNER or HOME BUYER *
A brief description of what is your current housing concern or when you plan to purchase your home.
31. Have you worked with a Housing Adviser Agency Before? *
32. Do you have a Closing Date?

Month Day Year
Date
33. Credit Report SOFT PULL AUTHORIZATION. *
Yes or No
34. Date *

Month Day Year
Have you had a Loan Modification before, if YES please enter the Date
35. Do you own another property? *

Yes No
36. Please check all that you feel describes your current financial position:
37. It is hard to: *

SAVE Pay Bills Make Home Repairs Decrease Credit Card Debt Pay Property Tax Go on vacation Afford Medication Pay Home Mortgage Increase Credit Score
38. Borrower Served in Armed Forces? *
39. Name of Lender on Current Loan. If none, skip to Question 42.
40. Are you behind in your Mortgage -, if yes # of Months
41. Have you applied or received a Modification before? if applicable
42. Received any Court or Legal Notices? *
43. Property Type where you currently live or would like to purchase. *
Single Two-Unit Three-Unit Four-Unit
44. Do you live in the Property? *
45. Monthly Gross Wages or Government Benefits Household Income *
INCLUDE BORROWER & CO-BORROWER INCOME
46. Borrower's Job Title
47. Borrower Employment Details *
Full-Time Part-Time Start Date / Self -Employed OR N/A
48. How often are you Paid *
Every 2 Weeks; Weekly; Twice a Month; Yearly
49. Co-Borrower Job Title
50. Co-Borrower Employment Details *
Full-Time Part-Time Start Date / Self - Employed OR N/A
51. Co-Borrower How Often are you paid *
Every 2 Weeks; Weekly; Twice a Month; Yearly
52. English Language Barriers? *
Is Head of Household English Proficient?
52. 1st CHOICE--Schedule 1st Counseling Session Appointment with Housing Adviser ? *
In Signature Box below, state whether you would like a Telephone of Face to Face Intake Session
53. Date- 1st CHOICE OFFICE HOURS: 10:30am - 4:30pm For URGENT ISSUES Mornings/Evenings/ Saturday. *

Month Day Year
DATE: CLICK CALENDAR TO THE RIGHT
54. Time *

: Hour Minutes AM/PM Option
55. 2nd CHOICE -- 1st Counseling Session

Month Day Year
DATE: CLICK CALENDAR TO THE RIGHT
56. Time

: Hour Minutes AM/PM Option
57. If URGENT: please describe the urgency including any deadline dates. *
STATE N/A if your issue is not Time-Sensitive
58. I understand that there are required Intake Documents in order to complete file for service. *
Enter YES or NO
59. Signature / Authorization: Soft Pull Credit Report

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse. Clear
Should be Empty: