Customer Intake Form "*" indicates required fields Step 1 of 3 33% CompanyThis field is for validation purposes and should be left unchanged.Applicant InformationName* First MI Last Address* Street Address City State / Province / Region ZIP / Postal Code Cell Phone:*Work Phone:Home Phone:E-mail address:* SS#*Birthdate:* MM slash DD slash YYYY Education Level:*Gender:* Male Female Ethnicity:* Hispanic Non-Hispanic Race:*Co-Applicant InformationName First MI Last Address Street Address City State / Province / Region ZIP / Postal Code Cell Phone:Work Phone:Home Phone:E-mail address: SS#Birthdate: MM slash DD slash YYYY Education Level:Gender: Male Female Ethnicity: Hispanic Non-Hispanic Race:Please check all that apply:Marital Status* Single Married Divorced Separated Widowed Foreign Born?* Yes No Are you a First-time Homebuyer (not owned in 3 years)?* Yes No Disabled?* Yes No Veteran?* Yes No Household Size*Annual Household Income $*(before taxes – include child support, pension, disability, etc.)Do you currently?* Rent Rent with a Housing Choice Voucher Own Other How Did You Hear About Our Organization?* Newspaper Bank Walk–In Flyer Staff Member Previous Customer Realtor Friend/Relative Festival/Fair Yard Sign Internet search Website Social Media Services I am interested in:* Homebuyer Education Credit Counseling/Money Management Home Repair Down Payment Assistance Mortgage Delinquency Counseling Consent* I certify that all of the above information is correct and true to the best of my knowledge. I understand that false or misleading information may be grounds for rejection of services. Furthermore, I understand that the completion of the application in no way guarantees me that I will receive housing assistance.Applicant Signature*Co-Applicant Signature Waiver and Authorization to Release Information The client recognizes that in order for Neighborhood Housing Partnership of Greater Springfield to provide its services, the referral source for the client, as well as other persons, firms or organizations will request NHP to furnish certain information concerning the clients’ financial condition. The client expressly authorizes NHP to: 1) disclose any information concerning the financial status of the client to the referral source and project partners; 2) obtain and review financial information concerning the client from the referral source and project partners as NHP deems necessary, 3) obtain and review the clients’ credit report (s) from the credit reporting agencies, 4) request verification of income and residence, and 5) collect copies of my loan application, supporting documentation and closing statement from my lender and/or closing company handling my loan. NHP agrees that all information in the client’s file will be otherwise kept confidential. The client agrees to hold NHP, their employees, officers and agents harmless from any claim, suit, action or demand in connection with any services rendered by NHP to the client. The client recognizes that NHP has no responsibility or obligation for any part of the loan approval/denial process. NHP has a commitment to provide quality services. If you have any concerns or complaints regarding the services provided by NHP, you may contact Rachel Goff, Executive Director, at (937) 322-4623. The client also authorizes NHP to disclose the client’s identity and his/her personal and financial information to a party collecting such information for research, the results of which are to be used by NHP and organizations like HUD, and to the following parties or for the following purposes: Client Signature*SS# last 4 digits*Client SignatureSS# last 4 digitsProperty Address:* Street Address City State / Province / Region Housing Counseling - Conflict of Interest DisclosureNeighborhood Housing Partnership of Greater Springfield, Inc. (NHP) creates and preserves affordable, quality housing and strong neighborhoods through partnerships of residents, government, and business. NHP is a non-profit 501©3 organization dedicated to increasing and preserving homeownership, promoting the development and rehabilitation of housing, and supporting vibrant, healthy neighborhoods. I understand that NHP offers the following housing counseling services in-house: Pre-purchase and post-purchase non-default individual counseling: One-on-one meeting with a certified counselor to assist the client with creating a sustainable budget/spending plan for their current household situation. Counselor also may assist the client in reviewing their credit report, as well as how to dispute errors and make needed corrections. Counselor will determine what goals the client has, and what affordable housing programs for which the client may qualify. Pre-purchase group education: A comprehensive, six-hour class to help prospective homebuyers learn about the home buying process and how to avoid common pitfalls. The course consists of three 2-hour sessions that are held on (3) Wednesday evenings with a certified instructor. Participants learn in a fun and upbeat atmosphere while forming bonds and sharing tips and experiences with one another. Course is offered onsite and virtually via Teams. Foreclosure Intervention individual counseling: One-on-one meeting with certified counselor for homeowners who have become delinquent in their mortgage payments. Housing counselor will assist homeowners in understanding the foreclosure process in the State of Ohio; budgeting; working with their lender; getting “back on track” with mortgage payments; and avoiding rescue scams. Financial, budgeting, and credit workshops: A proactive approach to improving household money management skills. Students learn how to improve credit scores, create a realistic budget, implement a savings plan, and learn financial goal setting. Typical workshops are 1.5 – 2.0 hours in length. Participants are encouraged to follow up with a one-on-one individual housing counseling session. I understand that NHP offers the following program for home repairs in-house: Home repair coaching and project management: Certified counselor and project manager provide homeowner with information and advice on home improvements to address health and safety concerns; property maintenance; grant options and process; what housing codes and housing enforcement procedures apply for the intended activity. Funds may address an emergency repair or an “age in place” modification. NHP provides individual housing counseling after which I will receive an action plan consisting of recommendations, possibly including referrals to other community agencies as appropriate. I understand that NHP may receive compensation from USDA and other lenders for packaging and/or loan originations. I may be referred to other services of the organization or other agencies as appropriate that may be able to assist with concerns that have been identified. I understand that I am not obligated to use any of the services offered to me. I understand that NHP provides information and education on numerous loan products and housing programs, and I further understand that the housing counseling I receive from NHP in no way obligates me to choose any of these loan products or housing programs. A counselor may answer questions and provide information but not give legal advice. If I want legal advice, I will be referred for appropriate assistance, but I am not obligated to use any of the services offered to me. I acknowledge that I have received a copy of NHP’s Privacy Policy and Client Termination/Close-out Policy. I acknowledge that I have received the following home inspection materials: HUD Forms "For Your Protection: Get a Home Inspection" and "Ten Important Questions to Ask Your Home Inspector", I have been informed of my rights and procedures related to the Lead Disclosure Rule, the EPA Renovation, Repair and Painting Rule, and the Lead Safe Housing Rule as it pertains to the rental or purchase of housing that may include pre-1978 housing, including HUD-assisted options. I understand that the following NHP services have an associated fee that I am responsible to pay: Homebuyer Education Course: $50.00 *Scholarships available to Clark County residents on a sliding scale with household incomes under 80% AMI. eHome America online HBE Course: $100.00 Tri-Merge Credit Reports with Scores – Individual / Joint: $47.05 / $94.10 Homeownership and Equity Protection Act (HOEPA) individual counseling session: $100.00 Client’s Signature*Client’s Signature
