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Advising Intake
Page 1
Applicant
First Name
Middle Initial
Last Name
Email
Phone
Enter with dashes. E.g. 123-456-7890
Phone Type
Please select...
Home
Work
Mobile
Street Address
City
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Is there another adult in your household who should be included as a part of the advising services?
Please select...
Yes
No
Co-applicant
First Name
Last Name
Email
What type of advising are you interested in?
Please select...
Mortgage Delinquency/Default
Rental/Eviction Prevention
Hidden Fields
Service File ID
Counseling/Education ID
Owner ID
Owner Role/Agency formula
Contact ID
Agency ID
Agency Name
Disclosure URL
Submit Redirect URL
Contact Name
Page 2
To demonstrate our commitment to equity and our service reach, we are required to collect demographic information from the clients we serve. Please answer the following demographic questions.
1.
What is your birth date?
MM/DD/YYYY
2.
What gender do you identify as?
Please select...
Female
Male
Trans female
Trans male
Trans non-binary
Non-binary
Other
3.
What is the highest degree or level of education you have completed?
Please select...
Less than HS Diploma
High school diploma or equivalent
Some post-secondary education
Certification from a vocational or technical training program
Associate's Degree
Bachelor's Degree
Master's or other graduate degree
4.
Are you a veteran?
Please select...
Yes
No
5
.
Are you active military?
Please select...
Yes
No
6.
Are you living with a disability?
Please select...
Yes
No
7.
Do you need language assistance or an interpreter
Please select...
Yes
No
8.
What language do you primarily speak?
Please select...
Amharic
English
Hmong
Karen
Somali
Spanish
Oromo
Other
Chose Not to Respond
Arabic
Armenian
ASL
Cambodian
Chinese - Cantonese
Chinese - Mandarin
Czech
French
French Creole
German
Greek
Gujarati
Hindi
Indonesian
Italian
Japanese
Korean
Persian
Polish
Portuguese
Russian
Swahili
Tagalog
Turkish
Ukrainian
Urdu
Vietnamese
9.
What is your current housing arrangement?
Please select...
Renting
Owning
Staying with family or friends
Homeless
Staying in a Shelter
Other
10. Do you live in a rural area?
Please select...
Yes
No
11.
What best describes your household type?
Please select...
Single Adult
Female-headed single parent household
Male-headed single parent household
Married/Domestic Partnership without dependents
Married/Domestic Partnership with dependents
Two or more unrelated adults
Other
12.
How many adults live with you?
13.
How many children live with you?
14.
What is your current marital status?
Please select...
Single
Married / Domestic Partnership
Separated
Divorced
Widowed
Unknown
Chose Not to Respond
15.
What is your race?
Please select...
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Other multiple race
Chose Not to Respond
15.1
What is the race of the other person you listed?
Please select...
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Other multiple race
Chose Not to Respond
16.
Are you Hispanic, Latino or Spanish origin?
Please select...
Yes
No
I choose not to respond
16.1
Is the other person you listed of Hispanic, Latino or Spanish origin?
Please select...
Yes
No
I choose not to respond
17.
Were you born outside of the United States?
Please select...
Yes
No
18.
Do you identify with any of the following immigrant or new American communities?
Please select...
No, does not apply
British/U.K.
Burmese (includes Karen and Karenni)
Cambodian
Canadian
Chinese
Dominican
Ethiopian
Filipino
German
Guatemalan
Haitian
Honduran
Hmong
Indian
Kenyan
Korean
Laotian
Liberian
Mexican
Nigerian
Oromo
Russian
Salvadoran
Vietnamese
Somali
Other
19.
Are you a first time homebuyer (you have not owned a home for the past 3 years)?
Please select...
Yes
No
20.
Are you a first generation homebuyer (your parents did not own a home)?
Please select...
Yes
No
How did you hear about us?
Please select...
HUD Outreach
Agency Outreach
Another Person
Lender
Another Agency
Real Estate Agent
Other
Page 3
Income
Current Employment Status
Please select...
Self-employed
Work full-time for employer
Work part-time for employer
Homemaker
Full-time student
Permanently unable to work
Unemployed and seeking work
Unemployed and not seeking work
Retired
Other
Employment Income/Salary
Employer Name
Gross Annual Income
Employment Start Date
Income Type
Please select...
Full-time Employment
Part-time Employment
Self-Employment
Occupation
Please select...
Administrative Assistant
Artist
Attorney
Automotive
Bank Teller
Carpenter
Casino
Construction
Cook
Custodian
Customer Service Representative
Day Care Provider
Driver - Delivery
Driver - Bus
Driver - Truck
Electrician
Engineer
Farmer
Grocery
Group home Provide
Health Care - Support Staff
Health Care Provider
Hospitality
House Keeper
IT/Technology
Landscaping
Maintenance/Janitor
Marketing
Manufacturing
Newspaper
Non-Profit Employee
Office Administrator
Painter
Plumber
Postal Worker
Public Service
Restaurant
Retail Clerk
Retired
Sales
School Administrator
Social Services
Teacher/Aide
Tourism
Veterinarian
Other
Do you have income from any other sources other than salary (child support, alimony, social security)?
Please select...
Yes
No
Additional Income
Income Type
Please select...
Spousal Support
Child Support
Investment income
Unemployment
SSI
SSDI
Income from Assets
Social Security
Other
Gross Annual Income
Page 4
Foreclosure/Mortgage Default Details
Why are you having trouble making your mortgage payment?
Is your mortgage a Reverse Mortgage (Home Equity Conversion Mortgage)?
Yes
No
Is there a
foreclosure sale (sheriff’s sale)
scheduled?
Yes
No
Have you had a loan modification in the past five years?
Yes
No
Have you filed for bankruptcy before?
Yes
No
Did your enter into a forbearance agreement?
Yes
No
What is the
forbearance end date?
First Mortgage Information
Provide the following information about your mortgage. Use exact information when possible. Otherwise, enter estimate to the best of your knowledge.
Year loan was taken out
Lender or Servicer Name
Type of Loan
Please select...
Fixed
Adjustable Rate (ARM)
Other
Type of Mortgage
Please select...
FHA
VA
USDA
GSEs
Private
Interest Rate
Current balance (amount owed)
Monthly mortgage payment
Months behind on mortgage
Please select...
Current
1-2 months behind
2-3 months behind
3-4 months behind
More than 4 months behind
Past Due Amount
Do you have a second mortgage?
Please select...
Yes
No
Second Mortgage Information
Provide the following information about your mortgage. Use exact information when possible. Otherwise, enter estimate to the best of your knowledge.
Lender or Servicer Name
Type of Loan
Please select...
Fixed
Adjustable Rate (ARM)
Other
Interest Rate
Current balance (amount owed)
Monthly mortgage payment
Months behind on mortgage
Please select...
Current
1-2 months behind
2-3 months behind
3-4 months behind
More than 4 months behind
Past Due Amount
Do you have Homeowners Association or other liens on your property
Please select...
Yes
No
Homeowners Association/Other Liens
Type
Please select...
Homeowners Association
Other
Company
Monthly Payment
Months Behind
Please select...
Current
1-2 months behind
2-3 months behind
3-4 months behind
More than 4 months behind
Amount Behind
Property Taxes
Are your property taxes escrowed?
Please select...
Yes
No
Property Taxes Details
Monthly Payment
Months Behind
Please select...
Current
1-2 months behind
2-3 months behind
3-4 months behind
More than 4 months behind
Amount Behind
Homeowners Insurance
Is your homeowners insurance escrowed?
Please select...
Yes
No
Homeowners Insurance Details
Amount Behind
Page 5
Rental Details
Are you facing a pending eviction?
Yes
No
Monthly rent
Number of months behind
Total amount behind