Foreclosure Prevention Intake Form

Are you a homeowner?

If you are not a homeowner but would like assistance from FHANC, please complete this intake form instead.

Preferred Language/ Idioma Preferido

First Name

Last Name

Phone Number

Street Address

City

State

Zip / Postal Code

County

How many years have you owned your home?

How much is your monthly mortgage payment?

Are you current on your mortgage payments?

Is your loan in forbearance?

What bank/lender owns your mortgage?

What is your annual household income?

What is your main source of income?

How many people are in your household?

How many minor children are in your household?

Does anyone in your household have a mental or physical disability?

Is anyone in your household 62 or older?

What is your gender?

What is your race?

What is your ethnicity?

What is your date of birth?

Brief Description of Issue:

How were you impacted by Covid-19?

How did you hear about Fair Housing Advocates?

Nombre

Apellido

Numero de Teléfono

Correo electrónico

Dirección

Cuidad

Estado

Código Postal

Condado

¿Eres inquilino o propietario?

¿Cuántos años ha vivido en su casa?

¿Número de personas en su familia?

¿Cuántos niños en su familia?

¿Cuál es el ingreso anual de su familia?

¿De dónde provienen su ingreso?

¿Alguien en su familia tiene una discapacidad?

¿Hay alguien en su familia mayor de 62 años?

¿Cuál es su género?

Etnicidad

Raza

Fecha de Nacimiento

Breve comentario sobre el asunto:

¿Cómo te afectó el Covid-19?

¿Quién te habló de nosotros?

Contact Information