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Advising Intake
Page 1
Hidden Fields
Service File ID
Counseling/Education ID
Owner ID
Owner Role/Agency formula
Contact ID
Agency ID
Agency Name
Disclosure URL
Agency Logo URL
Agency Email
Agency Phone
Agency Street Address 1
Agency Street Address 2
Agency City
Agency State
Agency Zip
Services Provided
1:1 Homebuyer Advising
1:1 Financial Wellness Advising
Refinance Advising
Financial Mgt/Budget Advising
Home Maintenance Advising
HECM Advising
Foreclosure Advising
Homeless Assistance
Rental Topics
Homebuyer Education
Purpose of Visit
Homeless Assistance
Rental Topics
Prepurchase/Homebuying
Non-Delinquency Post-Purchase
Reverse Mortgage
Resolving or Preventing Forward Mortgage Delinquency or Default
Resolving or Preventing Reverse Mortgage Delinquency or Default
Disaster Preparedness Assistance
Disaster Recovery Assistance
What
type of advising
are you interested in?
Homebuying
Mortgage Delinquency / Foreclosure Prevention
Reverse Mortgage / HECM
Mortgage Refinance / Post-Purchase
Rental / Eviction Prevention
How did you
hear about us
?
HUD Outreach
Agency Outreach
Another Person
Lender
Another Agency
Real Estate Agent
Other
Are you a recipient of Advancing Black Homeownership down payment assistance?
Yes
No
Applicant
First Name
Middle Initial
Last Name
Email
Phone
Phone Type
Please select...
Home
Work
Mobile
Street Address
City
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Applicant Details & Demographics Information
What is your
birth date
?
You must enter the date in this format: MM/DD/YYYY
Are you living with a
disability
?
Yes
No
What
gender
do you identify as?
Female
Male
Trans female
Trans male
Trans non-binary
Non-binary
Other
What is the highest degree or
level of education
you have completed?
Less than HS Diploma
High school diploma or equivalent
Some post-secondary education
Certification from a vocational or technical training program
Associate's Degree
Bachelor's Degree
Master's or other graduate degree
What is
your race
?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Other multiple race
I choose not to respond
Are you of
Hispanic, Latino or Spanish
origin?
Yes
No
I choose not to respond
Is there
another adult in your household who should be included
in advising services
?
Yes
No
Co-applicant
First Name
Last Name
Email
Co-applicant Details & Demographics Information
What is the
race of the additional adult
?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Other multiple race
I choose not to respond
Is the
additional adult
of
Hispanic, Latino or Spanish
origin?
Yes
No
I choose not to respond
Pre-purchase Advising Information
Has a lender
pre-approved
you for a mortgage loan?
Yes
No
Have you signed a
purchase agreement
?
Yes
No
How much money do you have in
savings
that you could use towards a down payment?
If yes, please provide the following
details for the property you have agreed to purchase
. If you don’t know you can leave fields blank.
Street Address
City
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Purchase Price
Loan Amount
Interest Rate
Closing Date
Lender
Page 2
Household & Demographic Information
To demonstrate our commitment to equity and our service reach, we are required to collect demographic information from the clients we serve. Please answer the following demographic questions.
Household Information
What best describes your
household type
?
Single Adult
Female-headed single parent household
Male-headed single parent household
Married/Domestic Partnership without dependents
Married/Domestic Partnership with dependents
Two or more unrelated adults
Other
What is your current
marital status
?
Single
Married / Domestic Partnership
Separated
Divorced
Widowed
Unknown
Chose Not to Respond
Additional Household Members
Do you have any
additional household members
?
Yes
No
Add Household Member
Name
Is this person
18 years or older
?
Yes
No
Is this person living with a
disability
?
Yes
No
Application Role
Include in HH Size
FT/PT
Housing Information
What is your
current housing
arrangement?
Renting
Owning
Staying with family or friends
Homeless
Staying in a Shelter
Other
Do you live in a
rural area
?
Yes
No
Monthly
rent
/
housing cost
Are you a
first-time homebuyer
(you have not owned a home for the past 3 years)?
Yes
No
Are you a
first-generation homebuyer
(your parents did not own a home)?
Yes
No
Language & Heritage Information
What
language
do
you primarily speak
?
English
Spanish
Somali
Hmong
Karen
Oromo
Amharic
Arabic
Armenian
ASL
Cambodian
Chinese - Cantonese
Chinese - Mandarin
Czech
French
French Creole
German
Greek
Gujarati
Hindi
Indonesian
Italian
Japanese
Korean
Persian
Polish
Portuguese
Russian
Swahili
Tagalog
Turkish
Ukrainian
Urdu
Vietnamese
Other
Chose Not to Respond
Do you need
language assistance
or an interpreter
Yes
No
Were you
born outside of the United States
?
Yes
No
Do you identify with any of the following
immigrant or new American communities
?
No, does not apply
British/U.K.
Burmese (includes Karen and Karenni)
Cambodian
Canadian
Chinese
Dominican
Ethiopian
Filipino
German
Guatemalan
Haitian
Honduran
Hmong
Indian
Kenyan
Korean
Laotian
Liberian
Mexican
Nigerian
Oromo
Russian
Salvadoran
Vietnamese
Somali
Other
Military Information
Are you
active military
?
Yes
No
Are you a
veteran
?
Yes
No
Page 3
Income Information
Do you receive any income from
employment
or
self-employment
?
Yes
No
Employment Income
Employer Name or Business Name
Gross
Annual Income
$
Employment
Start Date
Income Type
Full-time Employment
Part-time Employment
Self-Employment
Occupation
Please select...
Administrative Assistant
Artist
Attorney
Automotive
Bank Teller
Carpenter
Casino
Construction
Cook
Custodian
Customer Service Representative
Day Care Provider
Driver - Delivery
Driver - Bus
Driver - Truck
Electrician
Engineer
Farmer
Grocery
Group home Provide
Health Care - Support Staff
Health Care Provider
Hospitality
House Keeper
IT/Technology
Landscaping
Maintenance/Janitor
Marketing
Manufacturing
Newspaper
Non-Profit Employee
Office Administrator
Painter
Plumber
Postal Worker
Public Service
Restaurant
Retail Clerk
Retired
Sales
School Administrator
Social Services
Teacher/Aide
Tourism
Veterinarian
Other
Income Verification Type
Do you have income from any
other sources
other than salary (child support, alimony, social security)?
Yes
No
Additional Income
Income Type
Child Support
Spousal Support
Social Security
SSI
SSDI
Investment income
Unemployment
Income from Assets
Other
Monthly Amount
$
Annual Amount
Other Source Verification Type
When you click next on this page, your responses will be submitted and will no longer be editable. And you will be redirected to review and sign a privacy act notice and a information disclosure form.
Page 4
Mortgage Delinquency & Foreclosure Prevention Details
What is the
main reason
you've had trouble keeping up with your mortgage?
Reduction in Income
Loss of Income
Increase in Expense
Increase in Loan Payment
Medical Issues
Death of a Family Member
Divorce/Separation
Poor Budget Management Skills
Business Venture Failed
Other
We'd like to better understand your situation; what led to your current difficulties?
Have you had a
loan modification
in the past five years?
Yes
No
Have you
filed for bankruptcy
before?
Yes
No
Is there a
foreclosure sale (sheriff’s sale)
scheduled?
Yes
No
First Mortgage Information
Provide the following information about your mortgage. Use exact information when possible. Otherwise, enter estimate to the best of your knowledge.
Lender
or
Servicer
Name
In what
year
was the home purchased?
Interest Rate Type
Fixed
Adjustable Rate (ARM)
Other
Interest Rate
Is this a
Reverse Mortgage
/ Home Equity Conversion Mortgage?
Yes
No
Current balance (amount owed)
Monthly mortgage payment
How many
months behind
are you on your mortgage?
Current
1-2 months behind
2-3 months behind
3-4 months behind
More than 4 months behind
Past Due Amount
Do you have a
second mortgage
?
Yes
No
Second Mortgage Information
Provide the following information about your mortgage. Use exact information when possible. Otherwise, enter estimate to the best of your knowledge.
Lender
or
Servicer
Name
Interest Rate Type
Fixed
Adjustable Rate (ARM)
Other
Interest Rate
Current balance (amount owed)
Monthly mortgage payment
How many
months behind
are you on your mortgage?
Current
1-2 months behind
2-3 months behind
3-4 months behind
More than 4 months behind
Past Due Amount
Lien Position
Type
Lender/Holder Type
Do you have
Homeowners Association or other liens
on your property
Yes
No
Homeowners Association or Other Lien Information
Type
Homeowners Association
Other
Company
Monthly Payment
Amount Behind
How many
months behind
are you on your payments?
Current
1-2 months behind
2-3 months behind
3-4 months behind
More than 4 months behind
Property Tax Information
Are your
property taxes escrowed
?
Yes
No
I'm not sure
Property Taxes Details
Monthly Payment
Months Behind
Please select...
Current
1-2 months behind
2-3 months behind
3-4 months behind
More than 4 months behind
Amount Behind
Homeowners Insurance Information
Is your
homeowners insurance escrowed
?
Yes
No
I'm not sure
Homeowners Insurance Details
Amount Behind
When you click next on this page, your responses will be submitted and will no longer be editable. And you will be redirected to review and sign a privacy act notice and a information disclosure form.
Page 5
Rental Details
Are you facing a pending eviction?
Yes
No
Number of months behind
Total amount behind
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