FHPAP Program Intake

Are You A Homeowner Or A Tenant?

What Type of Assistance Do You Need?

I'm behind on my mortgageI'm behind on my rent
I'm behind on my utility bills

Contact Information

First Name

Last Name

Mailing Street

Mailing City

Mailing State

Mailing Zip/Postal Code

Personal Email

Mobile Phone

Information About Yourself

Birthdate

Race

Ethnicity

Tribal Affiliation

Tribe Affiliated With

Gender

Veteran

Information About Your Household

Monthly Household Income

How Many Adults (Including Yourself) Live In The Household?

How Many Children Live In The Household?

Is This A Single Parent Household?

Does Anyone In The Household Have A Disability?

How Long Has The Household Lived In The Residence?

Has Anyone In The Household Been Homeless In The Past 12 Months?

Currently Fleeing Domestic Violence?

Has The Household Received An Eviction or Foreclosure Notice?

Please Tell Us About The Mortgage Or Rent Payment You Are Behind On

Name of the Business That Payments Are Owed To

Contact Information For the Bank or Landlord That Payments Are Owed To

First Name

Last Name

Mailing Street

Mailing City

Mailing State

Mailing Zip/Postal Code

Work Email

Work Phone

Fax

For The Mortgage Or Rent Payment You Are Behind On

How Much Do You Owe?

What Is The Typical Monthly Payment?

If There Is An Account Number, What Is It?

Please Tell Us About Each Utility Bill You Are Behind On

Name Of Utility Company

How Much Do You Owe?

What Is The Typical Monthly Payment?

If There Is An Account Number, What Is It?

Please Tell Us Anything Else That Might Be Useful For Us To Know About Your Situation

How Did You Hear About Us

Contact Information