HFA Intake Form
Instructions:
Thank you for your interest in the Disaster Legal Assistance Collaborative (DLAC) Title Clearing Program. Our program aims to keep Californians housed in case of and after disasters. Please complete the form below and we will get back to you.
Title Clearing Program brought to you by:
Personal Details
First Name
Last Name
Phone
Email
Address Line 1
Address Line 2
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Postal Code
Demographic Information
This information is confidential and is only used for grant reporting purposes
Gender
Please select...
Male
Female
Non-Binary
Unknown
Age
Please select...
Child (Under 18)
Adult (Over 18)
Senior (Over 60)
Unknown
Ethnicity
Please select...
White not Hispanic Origin
Black not Hispanic Origin
Hispanic/Latino
Asian/Pacific Islander
Native American
Other race or ethnicity
Unknown
More than one ethnicity
County
Please select...
Alameda
Alpine
Amador
Butte
Calaveras
Colusa
Contra Costa
Del Norte
El Dorado
Fresno
Glenn
Humboldt
Imperial
Inyo
Kern
Kings
Lake
Lassen
Los Angeles
Madera
Marin
Mariposa
Mendocino
Merced
Modoc
Mono
Monterey
Napa
Nevada
Orange
Placer
Plumas
Riverside
Sacramento
San Benito
San Bernardino
San Diego
San Francisco
San Joaquin
San Luis Obispo
San Mateo
Santa Barbara
Santa Clara
Santa Cruz
Shasta
Sierra
Siskiyou
Solano
Sonoma
Stanislaus
Sutter
Tehama
Trinity
Tulare
Tuolumne
Ventura
Yolo
Yuba
Annual income before taxes
Household members over 18
Household members under 18
Are you a veteran or active military?
Please select...
Yes
No
Unknown
Do you have a disability?
Please select...
Yes
No
Unknown
Property Information
Description of Issue
Are you the legal or record owner of the property?
Yes
No
Unknown
Who is the legal or record owner of the property? Or who was the previous owner of the property?
Did you inherit the property?
Yes
No
How did you inherit the property?
Who pays the property taxes?
Are you behind on your mortgage?
Yes
No
How many payments are you behind by?
How much are you behind by?
Is there a question as to whom is the owner of the property?
Yes
No
Unknown
What documents do you have to prove that you are the owner of the property? (List deed, mortgage, property tax bill, home purchase contract).
Salesforce Info
Campaign ID
Contact Information