HFA Intake Form
INSTRUCTIONS:
Thank you for your interest in the 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.
LIMITED SCOPE AGREEMENT
Limited Scope Agreement: You will talk with an attorney in order for the attorney to obtain additional information about your case and to discuss your legal options. This call will contain brief legal advice to help you understand your options. Your conversation with the attorney will be confidential. The services you receive are free of charge. When you speak to the attorney, the attorney will give you advice on that day only and that call only. Your case may be referred to another volunteer attorney and a separate Limited Scope Agreement will need to be signed by you and the volunteer attorney. Do you agree to this?
I Agree
I Do Not Agree
Personal Details
First Name
Last Name
Phone
Email
Property Address
Address Line 2
City
Postal Code
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
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
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
