Intake Package Form Applicant InformationName* First Middle (optional) Last Suffix (optional) Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email Address Enter Email Confirm Email PhoneGender* Female Male Choose not to respond Current Street Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer Name* Employer Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Start Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Job 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 BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email Address Enter Email Confirm Email PhoneGender Female Male Choose not to respond Current Street Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer Name Employer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Job Title Mortgage Information (if applicable)Do you have a mortgage?* Yes No Lender Loan Number Monthly Mortgage PaymentTaxes Included Yes No Insurance Included Yes No If not included, what is the amount?Past Due AmountHow Many Months Behind?Missed Payments 30 60 90 120+ Interest RateTerm Months Remaining on MortgageYear Mortgage FinancedPlease 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 outcomeDemographic InformationEthnicity* Hispanic Non Hispanic Choose not to respond Ethnicity* American Indian/Alaskan Native Asian Black or African American Black or African American and White Native Hawaiian or other Pacific Islander White Choose not to respond (please choose only one)Marital Status* Single Married Separated Divorced Choose not to respond 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* No High School Diploma GED High School Diploma Some College, didn't graduate Vocational Certificate Associates Degree Bachelors Degree Masters Degree Doctorate Choose not to respond Household Financial InformationApplicant Income:Base Gross Monthly SalaryCo-Owner / Spouse Income:Monthly Gross IncomeApplicant Monthly Expenses:Mortgage/Rent Payment2nd Mortgage/Rent PaymentProperty 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 noteAuto: GasAuto: Parking, MaintenanceInsurance (auto, life, rental)Food (groceries)Credit CardsChild SupportHealth Care (out of pocket)Personal LoansChild CareTuition/BooksOtherOtherTotal Applicant ExpensesCo-Owner / Spouse Monthly Expenses:Mortgage/Rent Payment2nd Mortgage/Rent PaymentProperty 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 noteAuto: GasAuto: Parking, MaintenanceInsurance (auto, life, rental)Food (groceries)Credit CardsChild SupportHealth Care (out of pocket)Personal LoansChild CareTuition/BooksOtherOtherTotal Co-Owner / Spouse ExpensesCommentsThis field is for validation purposes and should be left unchanged.