Intake Application

Our agency is committed to ensuring the privacy of individuals and families who contact us for assistance. We realize that the concerns you bring to us are highly personal in nature. We assure you that all information shared both orally and in writing will be managed within legal and ethical considerations. Your "nonpublic personal information," such as your total debt, income, living expenses, and personal information concerning your financial circumstances will be provided to creditors, program monitors, and others only with your authorization and signature on the Counseling Authorization & Disclosure. We may also use anonymous aggregated case file information for the purpose of evaluating our services, gathering valuable research information, and designing future programs.

Types of information we gather about you:

• Information we receive from you orally, on applications, or on other forms, such as your name, address, social security number, assets, and income;
• Information about your transactions with us, your creditors, or others, such as your account balance, payment history, parties to transactions, and credit card usage; and
• Information we receive from credit reporting agencies, such as your credit history.

You may opt-out of certain disclosures:

• You have the opportunity to "opt-out" of disclosures of your nonpublic information to third parties (i.e., creditors), that is, elect not to make those disclosures.
• If you choose to "opt-out," we will not be able to answer questions from your creditors. If at anytime you wish to change your decision with regard to "opting-out," you may call us on our main phone.

Release of your information to third parties:

• So long as you have not "opted-out," we may disclose some or all of the information we collect, as described above, to your creditors or third parties where we have determined that it would be helpful to you, would aid us in counseling you, or is a requirement of grant awards that make our services possible.
• We may also disclose any nonpublic personal information about you or former clients to anyone as permitted by law (e.g., if we are compelled by legal process).
• Within our organization, we restrict access to nonpublic personal information about you to those employees who need to know that information to provide services to you. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your nonpublic personal information.

Applicant recognizes the need for counseling to solve specific housing and other related problems and pledges to fully cooperate with our agency's Housing Counselor. Applicant pledges specifically to provide honest and complete information; provide all necessary documents within requested or specified time frame(s); and promptly notify our agency of all changes in the status of the loan, contact info, etc. Regarding appointments, our housing counselors see clients *BY APPOINTMENT ONLY* and reserve the right to cease services after a client misses or reschedules two appointments without 24 hours notice.

Applicant authorizes the Counselor to act on his/her behalf to improve his/her housing situation and to obtain necessary services. Applicant authorizes the Counselor to obtain additional information from outside sources when necessary, including a credit report from one or all three credit reporting agencies. Applicant recognizes the need to exchange and/or pass on information, which will be used to assist Applicant in obtaining his/her housing needs.

Applicant authorizes our agency to share his/her information as required by our funders, and specifically to: (a) submit client-level information to data collection systems for our grants and (b) allow funders to open files to be reviewed for program monitoring and compliance purposes.

The Counselor pledges to preserve strict confidentiality concerning the applicant, and will neither give nor seek information except where others have a right to it. The Counselor will neither make decisions nor take action without the knowledge and consent of Applicant, and will at all times protect and promote the best interest of Applicant.

Our agency offers all of our services for FREE, at no charge to the client, excepting our homebuyer classes: $75-99 for online and $50 for local. Clients demonstrating an inability to pay may have the fee waived for local classes. From time to time our agency makes our clients aware of products and/or services that we believe offer good value to our clients. These products and/or services might be available directly from our agency, from lenders, developers, or other agencies with which our agency has a working relationship. You are under no obligation to use the products and/or services identified by our agency, whether from us or from industry partners.

Please understand that you are free to choose any lender, lending/financing product, or home from any entity regardless of the recommendations made by our agency representative and still participate in our counseling program. It is your right and responsibility to decide whether to engage in any course of counseling with our agency and to determine whether the counseling is suitable for you.

The individual action plan and direction of our counseling sessions will be based on the housing counseling action plan that we will develop together. The means to accomplish the outcomes and goals of your plan will evolve mutually between us and should be reviewed regularly during our counseling sessions. Additionally, you are under no obligation to obtain a mortgage or purchase a home and have the option to terminate the counseling program at any time for any reason.

Services provided by our agency include:

Counseling:  Pre-Purchase; Mortgage Delinquency & Default Resolution; Financial Management/Budget; and Rental Housing

Workshops:  Fair Housing Pre-Purchase Education; Predatory Lending Education; Pre-Purchase Home Buyer Education ($50 local, $75-99 online); Resolving / Preventing Mortgage Delinquency; Financial, Budgeting, and Credit; Non-Delinquency Post Purchase for Homeowners; and Rental Housing

I certify that I have read and understand the above statement(s). Any questions I had were previously discussed with the counselor and answered to my satisfaction.

Please ensure documents are clear and legible. Illegible documents will delay your counseling appointment.