Housing & Homeownership Intake
Personal Information
First Name:
Last Name:
Date:
Street Address:
City:
State:
Zip Code:
Cell Phone:
Home Phone:
Email:
Gender:
Male
Female
Other
Date of Birth:
Please explain:
Directions to your home:
Community/District:
Are you a veteran?
Yes
No
Do you have any special needs?
Yes
No
Please explain:
Ethnicity:
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific Islander
Hispanic
Choose not to respond
Other
Please specify:
Tribal Affiliation:
OST
Other
Enrollment #:
Please specify other ethnicity:
Marital Status:
Single
In a relationship
Engaged
Married
Divorced
Separated
Widowed
In a civil union
In a domestic partnership
What is your current living situation?
Own
Rent
Live with parents/relatives/friends
Other
Please specify other living situation:
What type of home do you live in?
Apartment
Single Family Home
Mobile Home-Singlewide
Mobile Home-Doublewide
Condo/Townhome
Temporary Housing
Other
Please specify:
Household Size:
Household refers to the # of people in your family unity and/or those you share finances/financial responsibility for.
# of adults:
18 and over
# of youth:
under 18
Total:
Physical Structure:
Physical structure refers those living/residing in your house and may or may not be related to you.
# of adults:
18 and over
# of youth:
under 18
Total:
AMI Level:
Annual Income:
Total Household Monthly Income:
Do you have children or are you raising grandchildren?
Yes
No
Are you a single parent?
Yes
No
Are you a grandparent raising your grandchild(ren)?
Yes
No
Have you ever owned a home?
Yes
No
Cost at time of purchase:
Current Value:
How did you obtain your home?
Tribal waitlist
BIA
HUD
Private Individual
Realtor/Realty agency
Other
Please specify:
Have you ever tried to get a home loan?
Yes
No
Did you receive the loan?
Yes
No
Why or why not?
Current Household Information
Please select the option that best describes your agreement with the following statements:
Never
Rarely
Sometimes
Often
Always
I live in a safe community:
I have pride in my home:
I have pride in my community:
I know, and am friendly with, my neighbors:
My home and community influences my well-being:
My community is healthy for my children:
My child(ren) can do schoolwork in my home without interruption from alcohol, overcrowding, noise, etc.)
My child(ren) has good grades:
My child(ren) behaves well in school:
My community is engaged and cooperative:
My family is familiar with the housing/homeownership process:
There are enough homes available for everyone:
What is missing from your community? (Stores, sidewalks, gas stations, etc.)
Employment Information
Employment Status:
Regular Employment
Self-Employed
Unemployed
Regular employment status?
Part-time (less than 34 hrs/wk)
Full-time (35 hrs/wk or more)
Is this work seasonal?
Yes
No
Self-employment status?
Part-time (less than 34 hrs/wk)
Full-time (35 hrs/wk or more)
Is this work seasonal?
Yes
No
Are you currently seeking employment?
Yes
No
Why aren't you seeking employment?
Student
Homemaker
Disabled
Retired
Other
Occupation/Title:
Length of Employment:
In months
Income Information
Gross Monthly Earned Income:
$
Monthly Assistance Income:
$
Other Income:
$
Please describe other income:
Total Monthly Income:
$
Do you feel you have the ability to save adequately?
Yes
No
Please explain:
Check any of the following lending products and services you currently use:
Payday Loans
Tribal Loan Program
Pawnshops
Loans with interest rates above 20%
Car title loans
I do not use these products and services
Loans with interest rates between 15-20%
Other
Please specify:
Have you seen your credit report in the last 6 months?
Yes
No
Do you know what your credit score is?
Yes
No
Credit score:
Needs Assessment
Are you interested in purchasing a home?
Yes
No
Which community/district?
What type of land is it?
TVCDC Development
My own land
Other
Please explain other type of land:
How would you currently rate your well-being in the following areas?
Poor
Fair
Neither fair nor good
Good
Excellent
Mental health
Emotional health
Spiritual health
Physical health
Financial health
Professional health
What specific service brought you in today?
Options for owning a home
Options for renting a home
Assistance with the home building process
Assistance with budgeting/spending plan
Assistance with setting up a bank account
Other (please specify):
Please specify other service(s):
What additional services are you interested in?
Coaching & Education
Programs & Services
What coaching & education service(s)?
Financial literacy education
Credit coaching
Home-buyer education/coaching
Other
Please specify other coaching & education service(s):
What home-buyer education/coaching service(s)?
Construction
Post-purchase education
Foreclosure prevention
Homebuyer insurance
Plumbing
Home maintenance
Other
Please specify other home-buyer education service(s):
What programs & services?
Credit builder loan
Housing program
Down-payment assistance
Closing cost assistance
Matched savings account/IDA
Income tax preparation and filing
Contractor development programs
Other
Some services will be referred to other organizations
Please specify other program(s) & service(s):
Please indicate which (if any) of these classes you are interested in participating in:
Building Native Communities: Financial Literacy
Credit When Credit is Due
Pathways Home: 1st Time Homebuyer
What or who directed you toward us today?
Radio
TV
Newspaper
Pamphlet
Email
Facebook or other social media
Lender
Realtor
H.E.R.O Partner
Family member or friend
Other non-profit
Internet
Walk-in
Website
Bulletin
Government agency
Community member
Unknown
Other
Please specify the lender:
Please specify the H.E.R.O partner:
Please specify the other non-profit:
Please specify the other way you were directed toward us:
I feel hopeful about the future.
Strongly Agree
Agree
Neither Agree nor Disagree
Disagree
Strongly Disagree
Additional Notes/Comments
Additional notes/comments:
Contact Information