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

Postal Code

Demographic Information

This information is confidential and is only used for grant reporting purposes

Gender

Age

Ethnicity

County

Annual income before taxes

Household members over 18

Household members under 18

Are you a veteran or active military?

Do you have a disability?

Property Information

Description of Issue

Are you the legal or record owner of the property?

YesNoUnknown

Who is the legal or record owner of the property? Or who was the previous owner of the property?

Did you inherit the property?

YesNo

How did you inherit the property?

Who pays the property taxes?

Are you behind on your mortgage?

YesNo

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?

YesNoUnknown

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