Advising Intake

Page 1

Applicant

First Name

Last Name

Enter noemail@noemail.com if you do not have an e-mail address.

Please Enter Your Email A Second Time

Enter noemail@noemail.com if you do not have an e-mail address.

The two emails you have entered above do not match. The next button at the bottom of this page will not work until the emails you have entered above match with each other.

Phone

Phone Type

Street Address

City

State

Zip Code

County

Were you referred to Homebuyer advising at One Roof by any of the following:

Is there another adult in your household who should be included as a part of the advising services? For the sake of our data management and reporting requirements, please fill out a separate intake for each adult member unless otherwise instructed by our staff.

Co-applicant

First Name

Last Name

Enter noemail@noemail.com if you do not have an e-mail address.

Please Enter This Person's Email A Second Time

Enter noemail@noemail.com if you do not have an e-mail address.

The two emails you have entered above do not match. The next button at the bottom of this page will not work until the emails you have entered above match with each other.

What type of advising are you interested in?

Hidden Fields

Service File ID

AMI ID

Counseling/Education ID

Owner ID

Contact ID

Account ID

Agency ID

Agency Contact ID

Agency Name

Disclosure URL

Page 2

To demonstrate our commitment to equity and our service reach, we are required to collect demographic information from the clients we serve. Please answer the following demographic questions.

1. What is your birth date?

2. What gender do you identify as?

Your Pronouns (Optional)

2.5 What gender does the other person you listed identify as?

Pronouns for other person you registered (Optional)

3. What is the highest degree or level of education you have completed?

4. Are you a veteran?

5. Are you active military?

6. Are you living with a disability?

7. Do you need language assistance or an interpreter

8. What language do you primarily speak?

9. What is your current housing arrangement?

10. Do you live in a rural area?

11. What best describes your household type?

12. How many adults live with you?

Number of Adults to Add

13. How many children live with you?

14. What is your current marital status?

15. What is your race?

15.1 What is the race of the other person you listed?

16. Are you Hispanic, Latino or Spanish origin?

16.1 Is the other person you listed of Hispanic, Latino or Spanish origin?

17. Were you born outside of the United States?

18. Do you identify with any of the following immigrant or new American communities?

19. Are you a first time homebuyer (you have not owned a home for the past 3 years)?

20. Are you a first generation homebuyer (your parents did not own a home)?

How did you hear about us?

Do you have any safety concerns?

If desired, please briefly describe your safety concerns:

Page 3

Do you currently have a checking or savings account?

What is your monthly household income? (Include income from all sources including employment, child support, social security, pension, etc.)

When did you start working for your primary employer?

If you are not presently employed, please leave blank.

Income

Current Employment Status

Employment Income/Salary

Employer Name

Income Type

Occupation

Do you have income from any other sources other than employment (child support, alimony, social security)?

Additional Income

Income Type

Gross Annual Income

Additional Information

How much money do you have in savings that you could use towards a down payment?

Has a lender pre-approved you for a mortgage loan?

Have you signed a purchase agreement?

If yes, please provide the following details for the property you have agreed to purchase. If you don’t know leave blank.

Street Address

City

State

Zip Code

Purchase Price

Loan Amount

Interest Rate

Closing Date

Lender

Page 4

Foreclosure/Mortgage Default Details

Why are you having trouble making your mortgage payment?

Have you had a loan modification in the past five years?

Have you filed for bankruptcy before?

Is there a foreclosure sale (sheriff’s sale) scheduled?

First Mortgage Details

Provide the following information about your mortgage. Use exact information when possible. Otherwise, enter estimate to the best of your knowledge.

Year House was purchased

Lender or Servicer Name

Type of Loan

Interest Rate

Current balance (amount owed)

Monthly mortgage payment

Months behind on mortgage

Past Due Amount

Do you have a second mortgage?

Second Mortgage Details

Provide the following information about your mortgage. Use exact information when possible. Otherwise, enter estimate to the best of your knowledge.

Lender or Servicer Name

Type of Loan

Interest Rate

Current balance (amount owed)

Monthly mortgage payment

Months behind on mortgage

Past Due Amount

Do you have Homeowners Association or other liens on your property

Homeowners Association/Other Liens

Type

Company

Monthly Payment

Months Behind

Amount Behind

Property Taxes

Are your property taxes escrowed?

Property Taxes Details

Monthly Payment

Months Behind

Amount Behind

Homeowners Insurance

Is your homeowners insurance escrowed?

Homeowners Insurance Details

Amount Behind

Page 5

Budget Worksheet

Please enter "0" if the budget item does not apply to you.

Net Monthly Income

Amount of money after taxes and deductions

Type/Name of Income Source 1

Income Amount 1

Type/Name of Income Source 2

Income Amount 2

Type/Name of Income Source 3

Income Amount 3

Type/Name of Other Income Source

Other Income Amount

Fixed Monthly Expenses

Doesn't change or changes only a small amount

Savings

Housing (Rent/Mortgage)

Heat/Gas

Electric

Water/Sewer

Garbage Collection

Car Payment

Student Loan

Childcare

Child Support/Alimony

Club/Union Dues

Remittance

Other Fixed Monthly Expense 1

Other Fixed Monthly Expense 1 Description

Other Fixed Monthly Expense 2

Other Fixed Monthly Expense 2 Description

Flexible Monthly Expenses

Have some control over and can be adjusted

Cable/Satellite Television

Internet Connection

Landline/Cell Phone

Groceries

Lunch (School/Work)

Eating Out

Alcohol/Tobacco Products

Lottery/Bingo

Other Entertainment

Other Entertainment Description

Barber/Beauty Shop

Personal Items/Toiletries

Laundry/Dry Cleaning

Household Items

Gas/Public Transportation

Religious Contributions

Membership Fees

Subscriptions

Pet Supplies/Care

Medical/Dental Co-pays

Medications

Credit Card 1

Credit Card 2

Credit Card 3

Spending Money

Other Flexible Monthly Expense 1

Other Flexible Monthly Expense 1 Description

Other Flexible Monthly Expense 2

Other Flexible Monthly Expense 2 Description

Periodic Expenses

Not a regular monthly expense
(Annual Cost/12 months = Monthly Budget Amount)

Tuition/Education

Car Insurance

Car Tabs/Registration

Car Repair/Maintenance

Additional Medical/Vision

Life/Disability Insurance

Renter's Insurance

Home Maintenance

Holidays/Birthdays/Gifts

Donations/Charity

Sports Fee/Equipment

Hobbies

Vacations

Clothing/Footwear

Other Periodic Expense 1

Other Periodic Expense 1 Description

Other Periodic Expense 2

Other Periodic Expense 2 Description

When you click next on this page, your responses will be submitted and will no longer be editable.

Contact Information