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 AgreeI Do Not Agree

Personal Details

First Name

Last Name

Phone

Property Address

Address Line 2

City

Postal Code

County

Demographic Information

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

Gender

Age

Ethnicity

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?

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

Did you inherit the property?

How did you inherit the property?

Who pays the property taxes?

Are you behind on your mortgage?

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?

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