Intake Form

Applicant Information

Name*

First Middle (optional) Last Suffix (optional)

Date of Birth*

Email Address

Enter Email Confirm Email

Phone

Gender*

Female
Male
Choose not to respond

Current Street Address*

Street Address Address Line 2 City State ZIP Code

Employer Name*

Employer Address*

Street Address Address Line 2 City State ZIP Code

Start Date*

Job Title*

Co-Applicant/Spouse Information (if applicable)

Do you have a co-applicant/spouse?*

Yes
No

Marital Status

Name

First Middle (optional) Last Suffix (optional)

Date of Birth

Email Address

Enter Email Confirm Email

Phone

Gender

Female
Male
Choose not to respond

Current Street Address

Street Address Address Line 2 City State ZIP Code

Employer Name

Employer Address

Street Address Address Line 2 City State ZIP Code

Job Title

Mortgage Information (if applicable)

Do you have a mortgage?*

Yes
No

Lender

Loan Number

Monthly Mortgage Payment

Taxes Included

Yes
No

Insurance Included

Yes
No

If not included, what is the amount?

Past Due Amount

How Many Months Behind?

Missed Payments

30
60
90
120+

Interest Rate

Term

Months Remaining on Mortgage

Year Mortgage Financed

Please enter a number from 1960 to 2030.

Type of Loan

Fixed
ARM

Have you had a loan modification in the last 5 years?

Yes
No

When and explain the outcome

Demographic Information

Ethnicity*

Hispanic
Non Hispanic
Choose not to respond

Ethnicity*

(please choose only one)

Marital Status*

Children*

Yes
No

Ages

Family Size*

Are you disabled?*

Yes
No
Choose not to respond

Are you a US Citizen?*

Yes
No

Have you filed bankruptcy?*

Yes
No

When was your bankruptcy discharged?

Type of Bankruptcy

Chapter 7
Chapter 13

Highest Level of Education*

Household Financial Information

Applicant Income:

Base Gross Monthly Salary

Co-Owner / Spouse Income:

Monthly Gross Income

Applicant Monthly Expenses:

Mortgage/Rent Payment

2nd Mortgage/Rent Payment

Property taxes & insurance (if not escrowed)

Housing: Utility (gas)

Housing: Utility (electric)

Housing: Utility (water/sewage)

Housing: Utility (cable/other)

Telephone (cellular/land line)

Auto: Car note

Auto: Gas

Auto: Parking, Maintenance

Insurance (auto, life, rental)

Food (groceries)

Credit Cards

Child Support

Health Care (out of pocket)

Personal Loans

Child Care

Tuition/Books

Other

Total Applicant Expenses

Co-Owner / Spouse Monthly Expenses:

Mortgage/Rent Payment

2nd Mortgage/Rent Payment

Property taxes & insurance (if not escrowed)

Housing: Utility (gas)

Housing: Utility (electricity)

Housing: Utility (water/sewage)

Housing: Utility (cable/other)

Telephone (cellular/land line)

Auto: Car note

Auto: Gas

Auto: Parking, Maintenance

Insurance (auto, life, rental)

Food (groceries)

Credit Cards

Child Support

Health Care (out of pocket)

Personal Loans

Child Care

Tuition/Books

Other

Total Co-Owner / Spouse Expenses

Phone

This field is for validation purposes and should be left unchanged.

HID Housing Counseling Agency

A HUD Approved Organization

Applicant Information

Co-Applicant/Spouse Information (if applicable)

Mortgage Information (if applicable)

Demographic Information

Household Financial Information

Applicant Income:

Co-Owner / Spouse Income:

Applicant Monthly Expenses:

Co-Owner / Spouse Monthly Expenses:

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