Mortgage Delinquency/Default Advising Intake

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Page 1

Are you working with any other organizations offering foreclosure services?

ATTENTION!

If you are working with another organization, there is no need to apply for additional counseling. You may only work with one advisor.

STOP the application, and contact your current advising agency for more information.

Applicant

First Name

Middle Initial

Last Name

Phone

Enter with dashes. E.g. 123-456-7890

Phone Type

Preferred Contact Method

Social Security Number

Acceptable formats are : ###-##-#### or #########

1. What is your birth date?

MM/DD/YYYY

Street Address

City

State

Zip Code

Is there another adult in your household who should be included as a part of the advising services?

Co-applicant

First Name

Last Name

Social Security Number

Acceptable formats are : ###-##-#### or #########

1. What is your co-applicant's birth date?

MM/DD/YYYY

Hidden Fields

What type of advising are you interested in?

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.

2. What gender do you identify as?

2. What gender does the other person you listed
identify as?

3. What is the highest degree or level of education you have completed?

4. Are you a veteran?

5. Are you active military?

6. Are you living with a disability?

7. Do you need language assistance or an interpreter

8. What language do you primarily speak?

9. What is your current housing arrangement?

10. Do you live in a rural area?

11. What best describes your household type?

12. How many adults live with you?

13. How many children live with you?

14. What is your current marital status?

14. What is the current marital status of the other person you listed?

15. What is your race?

15.1 What is the race of the other person you listed?

16. Are you Hispanic, Latino or Spanish origin?

16.1 Is the other person you listed of Hispanic, Latino or Spanish origin?

17. Were you born outside of the United States?

What is your Country of Origin?

What is the last country you held citizenship in? For Example: Born in America, "United States of America" vs. Immigrated from another country, select that country name from the list.

18. Do you identify with any of the following immigrant or new American communities?

Hidden Fields

19. Are you a first time homebuyer (you have not owned a home for the past 3 years)?

20. Are you a first generation homebuyer (your parents did not own a home)?

How did you hear about us?

Page 3

Income

Current Employment Status

Employment Income/Salary

Employer Name

Gross Annual Income

Employment Start Date

Income Type

Occupation

Do you have income from any other sources other than salary (child support, alimony, social security)?

Additional Income

Income Type

Gross Annual Income

Page 5

HSCP Authorization Disclosures Privacy Policy Form

To complete your application a signed release of the form entitled "HSCP Authorization Disclosures Privacy Policy" is required. The application will not be considered complete until the form has been submitted to your counselor. You may choose one of the following methods to submit the form:

Submission Type Preference

Now: I will download the form now, and attach the signed copy as a pdf before finalizing my response!Later: I am requesting the form be sent via email, I understand application is not complete until I sign and return the form.Accommodation: I will call to make an appointment at the office to sign the form in person, I understand application is not complete until I sign and return the form.

HSCP Authorization Disclosures Privacy Policy e-form (signed)

Click here to download the form

Optional

If you have any additional documents either requested by your counselor, or that you would like to share with your counselor to expedite your case, upload them here:

Disclaimer: Email is the primary method of contact for follow up instructions and exchanging additional application materials. It is your responsibility to check your email daily and respond to counselor requests as soon as possible!

If you require accommodation, contact your counselor within 48 hours to create a plan for how they can reach you going forward.

If you have additional questions, contact us at:

Phone: 612-305-7147 or 612-305-7237

Email: MFPP@tchabitat.org

Once you click 'submit', the form may take a minute to prepare the summary page.

DO NOT NAVIGATE AWAY FROM THE PAGE. You will have a chance to review and print/save your answers before you confirm submission on the next screen.

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