CHN Class Registration and Intake Application

Page 1

Please use the page numbers above to navigate to specific areas of the form

Welcome to CHN Housing Partners' Class Registration and Intake Application! We look forward to working with you.

Please indicate below which classes you are signing up for. You will receive an e-mail confirmation once we have enrolled you in your preferred class series.

July Classes (If you would like to attend both Homebuyer and Financial Management Classes, please select both options.)

Page 2

Applicant and Co-Applicant Details

In this section, please enter your most up to date contact information and demographic information.

CHN Housing Partners (CHN) 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 verbally and/or in writing will be managed within ethical and legal consideration. Additionally, we want you to understand how we use the personal information we collect. Please carefully review this notice as it describes our policy regarding the collection and disclosure of your nonpublic, personal information.

CHN's Privacy Policy

The Applicant (and Co-Applicant, if applicable) should be an adult member of your household that will be able to represent, provide information for, and make decisions on behalf of your household.

Applicant Information

Applicant first name

Applicant last name

Applicant home phone

Applicant cell phone

Applicant email address

Re-enter email address

Confirmation

Applicant Social Security number

Confirm Social Security Number

Confirmation

Applicant mailing street

Applicant city

Applicant state

Applicant zip code

Applicant primary language

Applicant gender

Applicant birthdate

Enter date in MM/DD/YYYY format

Applicant marital status

Applicant race

Applicant ethnicity

Applicant highest education

Applicant disabled

Applicant military status

Applicant citizenship status

Applicant driver's license number

How did you hear about us?

Is there a Co-Applicant?

YesNo

Co-Applicant Information

Co-Applicant first name

Co-Applicant last name

Co-Applicant cell phone

Co-Applicant email address

Co-Applicant Social Security number

Confirm Social Security number

Confirmation

Co-Applicant primary language

Co-Applicant gender

Co-Applicant birthdate

Enter date in MM/DD/YYYY format

Co-Applicant marital status

Co-Applicant race

Co-Applicant ethnicity

Co-Applicant highest education

Co-Applicant disabled

Co-Applicant military status

Co-Applicant citizenship status

Co-Applicant driver's license number

Do both applicants want to be registered for this class?

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Household Members

Please enter additional members who reside in your household (i.e. children, dependents, other family members, etc.). Use the "Add Additional Household Member" link to add as many as you need.

You do not need to re-enter Applicant or Co-applicant (if applicable) information here.

Please prepare for upload: For each household member, be prepared to provide verification that they are your dependents - such as Social Security Cards and Birth certificates

Do you have Additional Household Members to report?

YesNo

Household Member

Full name

Birthdate

Enter date in MM/DD/YYYY format

Social security #

Gender

Disabled

Race

Ethnicity

Education attainment

Employment status

Citizenship status

Relationship to Applicant

Currently attending school?

YesNo

Name of school

Grade

Page 4

Current Income Sources and Public Benefits

Please enter all sources of Income and Public Benefits that your household is CURRENTLY receiving, for all household members over the age of 18.

Use the "Add Additional Income Source" link to add as many as you need

Current Annual Income is the estimated income for the current year including any wages,

benefits, alimony, child support and other forms of financial income or support.

Income includes: Full-time employment, part-time employment, self-employment, spousal support, child support, investment income, Social security, SSI, SSDI, income from assets, pension/annuity, unemployment, adoption subsidy, short term disability, long term disability, veteran's benefits, zero income, family contribution, other

Public benefits include: Food stamps, WIC, ADC, OWF/TANF, rental subsidy, utility allowance, other public benefit

Do you have Current Income to report?

YesNo

Current Income or Public Benefit Source

Income earner's name

Enter the Household Member who this income belongs to

Income / Benefit type

Job title

Provide the Job Title for Employment types, if applicable

Employment Start Date

Please take the total income you received in the last 30 days and multiply by 12 to determine your annual income:

Current annual income amount

Please estimate to the best of your ability. Our staff will review your documents and provide a full eligibility determination.

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Assets Declaration

If you are taking Homebuyer classes, or intend on applying for down payment assistance and/or first-time homebuyer programs, knowing your current assets helps us have a better understanding of what products and programs you may be eligible for.

Please enter all liquid Assets you have control over for all household members over the age of 18. Liquid assets are cash on hand or assets in any other form that can be converted to cash within 20 days (SSA.gov)

Asset types include: Bank Accounts - Savings and/or Checking, Investment Accounts, Retirement, Certificates of Deposit, Cash on Hand, Pre-paid Debit Cards, Health Savings Accounts, Life Insurance Cash Value

Do you have Assets to report?

YesNo

Asset

Asset Type

Value

Please estimate to the best of your ability - enter 0 if unsure

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Documentation is not required to attend; however, the following items may be helpful to us as we work with you.

Photo identification & Social Security cards

If taking photos with your phone/camera, you can line up your IDs and Social Security cards within one image, instead of one at a time

Income Documents (30 days)

Do you have other supporting documents to upload? (Other items could include a pre-qualification letter, a referral from a lender, etc.)

YesNo

Other Documents

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Acknowledgement & Submit

I/we certify that all provided information is correct to the best of my knowledge and have received a copy of CHN's Privacy Policy. I/we authorize CHN Housing Partners to verify all information contained on this online form and to pull my credit report.

By typing my full name below, I hereby authorize CHN to release nonpublic personal information it obtains about me to any third parties necessary to provide me with the services I requested. I acknowledge that I have read and understand the above privacy practices. I understand I will receive a copy of all information submitted at the email address I provided on Page 2, "Applicant E-mail Address".

Applicant signature

Co-Applicant signature

Applicant acknowledgement date

Co-Applicant acknowledgement date