Housing Counseling Intake Form

Please fill in this simple expense sheet*

	Amount per Month
Housing (Rent or Mortgage + HOA fees)
Utilities (Electric, Gas, Water, Trash, Sewer)
Groceries / Restaurants
Communications (Phone, Internet)
Communications (Phone, Internet)
Medical Costs (Insurance, Co-Pays and Prescriptions)
Insurance (auto, health, life,pet)
Auto Loans
Gas and Auto Maintenance Costs
Clothing / Dry Cleaning / Uniforms
Child or Elder Care Costs
Student Loans
Credit Card Payments
Other debts (child/spousal support, loans)
Other costs not listed above

What is your household's monthly income before taxes or deductions? *
Source of Income (Wages, SSDI, SSI, Unemployment, etc)*
To the best of your knowledge, what is your current credit score?*
Please upload an image of your most recent credit report if you have one (NOT required). Want to download your report for free? www.annualcreditreport.com

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I hereby verify that I have received Fair Housing information/material regarding rights and remedies available under federal, state, and local fair housing and civil rights laws. Counseling services and other forms of assistance that may be offered by Lake County Housing Authority, its affiliates or directors, officers, employees, agents or partners may also be offered by other providers. You are under no obligation to utilize services from Lake County Housing Authority, regardless of the recommendations made by counselors. Housing Counseling clients are not obligated to use any program or service offered by LCHA, their affiliates or partners. The Office of Housing Counseling will provide information on alternative programs and services. Clients should consider a variety of options and select the resources that best addresses their needs. Signature*

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Today's Date*

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LCHA's Privacy Policy

Please read LCHA's Privacy Policy regarding your nonpublic personal information:
Regarding your nonpublic personal information:*

OPT-OUT: I request that LCHA make no disclosures of my nonpublic personal information to third parties other than project partners and those permitted by law. By choosing this option, I understand that LCHA will NOT be able to answer any questions from my creditors. I understand that I may change my decision any time by contacting LCHA.OPT IN / RELEASE: I hereby authorize LCHA to release nonpublic personal information it obtains about me to my creditors and any third parties necessary to provide me with the services I requested. I acknowledge that I have read and understand the above privacy practices and disclosures.
Privacy Policy & Ability to OptOut: I have read and received a copy of LCHA's HSCP Authorization and Disclosure as well as the Privacy Policy, including my option to opt out of the above terms and the release/disclosure ofany nonpublic, personal information.*

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For Your Protection, Get a Home Inspection
I have received information on Lead and the Importance of Home Inspections

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Please read the following Disclosure to Client and Privacy Policy