Intake Form

First Name

Last Name

Email

Street Address

City

State

ZIP Code

Work Phone

Date of Birth (mm/dd/yyyy)

Marital Status Marital StatusMarriedUnmarried

Dependent 1 Name

Home Phone

Dependent 2 Name

Dependent 1 Age

Dependent 3 Name

Number of Dependents

Dependent 2 Age

Dependent 3 Age

Dependent 4 Name

Dependent 4 Age

Do you have a co-applicant? Do you have a co-applicant? Yes No

Dependents' Names & Ages

Co-Applicant's First Name

Co-Applicant's Last Name

Co-Applicant's Street Address

Co-Applicant's City

Co-Applicant's State

Co-Applicant's ZIP Code

Co-Applicant's Home Phone

Co-Applicant's Work Phone

His/Her D.O.B. (mm/dd/yyyy)

Your Employer

Your Annual Income

Co-Applicant's Employer

His/Her Annual Income

Source of Other Income

Annual Other Income

Total Annual Income

Homebuyer Education, Credit Coaching, Financial Coaching/Money Management, Home Repair, Foreclosure Intervention/Mortgage Delinquency Counseling, Down Payment Assistance, USDA Loan

Have you owned a home in the last 5 years? Have you owned a home in the last 5 years? Yes No

Do you have a contract on a home? Do you have a contract on a home? Yes No

Are you working with a realtor? Are you working with a realtor? Yes No

Have you contacted a lender? Have you contacted a lender? Yes No

Is the home within the city limits? Is the home within the city limits? Yes No

Is the home your primary residence? Is the home your primary residence? Yes No

Does the home have three or less dwelling units? Does the home have three or less dwelling units? Yes No

What repair or improvement does the home need?

How did you hear about our programs?