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Donate
Resources
Rental
Path to Homeownership
Financial Literacy Education
Key Certificate Programs
Other Housing Counseling Services & Resources
Upcoming Events & Webinars
Employment Opportunites
About Us
Contact Us
Donate
Client Intake Form
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Client Intake Form
Client Intake
Applicant Information
Service Type
*
Select Service
Pre-Purchase/Homebuying counseling
Homeowner Counseling
Disaster Recovery Counseling
Homeless Counseling
Mortgage Delinquency Assistance Counseling
Rental Topic Counseling
Disaster Preparedness Counseling
Reverse Mortgage Counseling
Financial Capability Counseling
Other
Type of HUD Assistance
*
Select HUD Program
Rental Voucher
Place based Rental Assistance
Homeownership voucher
Other HUD program
Not Applicable
Applicant Name
*
Applicant Name
First Name
First Name
Last Name
Last Name
Applicant Phone
*
Applicant Email
*
Applicant Age
*
Applicant Birth Date
*
Street Address
*
Apt or Suite
City
*
State
*
Zip Code
*
Applicant Race
*
American Indian / Alaska Native
Asian
Black or African American
Native Hawaiian / other Pacific Islander
White
Chose not to respond
Check all that apply
Applicant Hispanic?
*
Yes
No
Applicant Disabled?
*
Yes
No
Applicant Gender
*
Male
Female
Other / Non-conforming
Marital Status
*
Applicant Credit Score
*
Applicant Monthly Credit Debt Amount
*
English Proficient?
*
Yes
No
Applicant Veteran?
*
Yes
No
Applicant Active Military?
*
Yes
No
First-time Homebuyer
*
Yes
No
Do you?
*
Rent
Own
Other
If you rent, how much do you pay and how long have you lived at this address?
*
Household Size
*
Annual Household Gross Income
*
How much money do you have saved for housing in your accounts now?
*
# of Dependents
*
Applicant Highest Level of Education
*
Select Education Level
High School/GED
College
Some College / Trade School
Graduate School
How did you hear about us?
*
Website
Social Media
Friend/Family Member
Employer
Other
First Employer Info
Employer 1 (applicant)
*
Start Date 1 (applicant)
*
# of years at employment 1 (applicant)
*
Town you work in 1 (applicant)
*
Occupation 1 (applicant)
*
Gross Monthly Income 1 (applicant)
*
Additional Employer/Income Info
Employer 2 (applicant)
*
Start Date 2 (applicant)
*
# of years at employment 2 (applicant)
*
Town you work in 2 (applicant)
*
Occupation 2 (applicant)
*
Gross Monthly Income 2 (applicant)
*
Other Income (applicant)
*
Select Other Income Type
None
Alimony
Child Support
Cash Assistance
Food Stamps
Pension
SSI
SSD
Service Connection
Survivor Benefits
TANF
TRA
Unemployment
Workers Compensation
Other
If you selected other, please explain:
2nd Household Member Info
Name - 2nd Household Member
Name - 2nd Household Member
First Name
First Name
Last Name
Last Name
Email - 2nd Household Member
Phone - 2nd Household Member
Race - 2nd Household Member
American Indian / Alaska Native
Asian
Black or African American
Native Hawaiian / other Pacific Islander
White
Chose not to respond
Check all that apply
Hispanic? - 2nd Household Member
Yes
No
Disabled? - 2nd Household Member
Yes
No
Gender - 2nd Household Member
Male
Female
Other / Non-conforming
Age - 2nd Household Member
Date of Birth - 2nd Household Member
Veteran - 2nd Household Member
Yes
No
Active Military - 2nd Household Member
Yes
No
Credit Score - 2nd Household Member
Employer - 2nd Household Member
Start Date - 2nd Household Member
# of years at employment - 2nd Household Member
Town you work in - 2nd Household Member
Occupation - 2nd Household Member
Gross Monthly Income - 2nd Household Member
3rd Household Member Info
Name - 3rd Household Member
Name - 3rd Household Member
First Name
First Name
Last Name
Last Name
Email - 3rd Household Member
Phone - 3rd Household Member
Race - 3rd Household Member
American Indian / Alaska Native
Asian
Black or African American
Native Hawaiian / other Pacific Islander
White
Chose not to respond
Check all that apply
Hispanic? - 2nd Household Member
Yes
No
Disabled? - 3rd Household Member
Yes
No
Gender - 3rd Household Member
Male
Female
Other / Non-conforming
Age - 3rd Household Member
Date of Birth - 3rd Household Member
Veteran - 3rd Household Member
Yes
No
Active Military - 3rd Household Member
Yes
No
Credit Score - 3rd Household Member
Employer - 3rd Household Member
Start Date - 3rd Household Member
# of years at employment - 3rd Household Member
Town you work in - 3rd Household Member
Occupation - 3rd Household Member
Gross Monthly Income - 3rd Household Member
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