OUTREACH HOUSING ASSISTANCE INTAKE

HOMEOWNER OUTREACH SIGN-IN FORM

This information is used ONLY to service your housing needs and will not be shared without your permission. Please answer all questions and enter N/A where applicable.

REGISTRATION FOR:

A. HAF 2.0 HomeOwner Grant Application Computer Assistance

B. LIHEAP Utility Assistance

C. Drop Off INTAKE Documents / Assist with uploading Grant Documents

IHDA will be available to answer questions and assist with any specific Grant Applicagtion and Eigibiiity Issues.

THANK YOU For contacting AGORA to stay up-to-date on Housing Aassistance Resources and Information.
Date*

MonthDay Year
Please describe your Housing concern - "Your Story". Do you believe it is COVID-19 related?*
Which Outreach Help Day would you like to attend? *
Did you apply for HAF Homeowner Grant?*
If YES, what was the latest "Status" in the Grant Portal or Received Email?*
Full Name of person on Mortgage*

First Name Last Name
Co- Borrower on Mortgage Loan?*
Enter NO or the Co-Borrower's Name as show on the Mortgage
Co-Borrower Relationship
Spouse , etc.
Marital Status*
Phone Number*

Area Code Phone Number
Phone Type*
Can We Text Appt. Reminders?*
Type YES or NO
E-mail
IF YOU DO NOT HAVE AN EMAIL - ENTER: (noemail@gmail.com) and you will be assisted.
Property Type*
Property Address*

Street Address

Suite or Apt Number

City State / Province

Postal / Zip Code Country
Is Homeowner currently living in the Property?*
Mortgage Loan Type:
Has homeowner received a Forbearance or Modification with Lender?*
Is the Home currently or Homeowner considering Reverse Mortgage? *
Is the Homeowner a Veteran?*
Birth Date*

Month Day Year
Gender*

MaleFemaleChoose not to respond
Ethnicity*

HispanicNon-Hispanic
Race*

Am Indian /Alaskan NativeAm Indian / Alaskan Native and BlackAm Indian/ Alaskan Native WhiteAsianAsian and WhiteBlack or African AmericanBlack or African American and WhiteWhiteNative Hawaiian or Other Pacific IslanderHispanicChoose not to respond
Education*
Language*

EnglishSpanishOther
Live in Rural Area*
Household Annual Gross Income*

Less than $25,000$25,500 - $41,500$41,600 - $61,500Over $61,000
Number in Household?*

1234
Request assistance with:*

SAVINGMortgage PaymentsHome RepairsCredit Card DebtPay Property TaxImprove CreditAfford MedicationBudget ManagementWeatherization- LIHEAPInternet / Computer / Grant Computer Submission AssistAssistance with setting up an email
Need Special Assistance
SIGNATURE:
Your Typed Name above will represent Signature Authorization and, if applicable, a Photo Release.
Should be Empty: