1 Minneapolis Office: 1930 Glenw ood Ave Minneapolis, MN 55405 Neighborhood Housing Services of Minneapolis, NMLSR#394817 Community NHS, dba NeighborWorks Home Partners, NMLSR#363923 Donna Corbo Lending Manager NMLSR#756908 TEL: 651-348-5079 FAX: 651-292-0473 dcorbo@nwhomepartners.org Nicole Meyer Lending Program Specialist TEL: 651-348-5080 FAX: 651-292-0473 nmeyer@nwhomepartners.org Annie Reierson Lending Program Specialist TEL: 651-348-5087 FAX: 651-292-0473 areierson@nwhomepartners.org Minneapolis Office TEL: 612-594-7150 FAX: 612-594-7151 HOME IMPROVEMENT INTAKE FORM PLEASE PRINT CLEARLY AND CONTACT US WITH ANY QUESTIONS Client Full Legal Name: Phone Numbers: Home: ( ) - Cell: ( ) - Work: ( ) - Best time to reach you / preferred form of contact: Email address: Date of Birth: Social Security Number: Marital Status: Married Not Married Legally Separated The following information is requested for all Clients by the federal government for certain types of loans related to a dwelling in order to monitor the lender s compliance with equal credit opportunity, fair housing, and home mortgage disclosure laws. You are not required to furnish this information, but are encouraged to do so. The law provides that a lender may not discriminate on the basis of this information, or on whether you choose to furnish it. However, if you choose not to furnish the information and you have made this application in person, under federal regulations the lender is required to note ethnicity, race, and sex on the basis of visual observation or surname. If you do not wish to furnish the information, please check: Sex: Male Female Ethnicity: Hispanic or Latino Not Hispanic or Latino Race (select 1 or more): White Asian Black or African American American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander I do not wish to furnish this information -------------------------------------------------------------------------------------------------------------------------------------------------- Co-Client Full Legal Name: Phone Numbers: Home: ( ) - Cell: ( ) - Work: ( ) - Best time to reach you / preferred form of contact: Email address: Social Security Number: Marital Status: Date of Birth: Married Not Married Legally Separated Relationship to Client: Co-Head of Household Other Adult Spouse Sex: Male Female Ethnicity: Hispanic or Latino Not Hispanic or Latino Race (select 1 or more): White Asian Black or African American American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander I do not wish to furnish this information
2 List any/all owners (other persons listed on title) that do not live in the household also provide copy of ID and proof of address (i.e. Utility bill, lease, etc.) Name(s) Current Address/ Contact info ALL HOUSEHOLD MEMBERS: Please list every household member not already listed as client or co-client. (If you need additional space, please continue on the back of this page.) What is the total number of people living in your home, including yourself, co-client, and all children? # PROPERTY INFORMATION: Address: City: MN Zip: Building Type: Single Family tri-plex Townhome Condominium Duplex four plex Twin home Mobile Home Do you own and occupy this property as your primary residence? Yes No If no, please explain Did you purchase your home through a Contract for Deed? If yes, what is the Deed holder s name and contact information: Yes No What year did you purchase your home? If purchased within the last 24 months, did you own or rent your previous residence? Do you currently have a mortgage? Yes No Own Rent N/A If purchased within the last 24 months, please list your previous address: If you rented, please list your previous landlord information. If you owned, please list your previous mortgage holder: Is your house for sale or do you plan to sell it within the next 12 months? Have you received any loans or grants from a government or non-profit organization in the past? Yes No Yes No Have you applied or are you in the process of applying for funding with any other agencies or banks? Yes No If yes, who are you working with or who have you worked with in the past? Please list the name or organization and type of funds received / applying for:
3 Do you own any other real estate or land? Yes No If yes, please list the address, type of property owned, and purpose: INCOME INFORMATION: List all household members, every source of income received in the last 2 years (even if it is zero), the start/end date(s) for that income source (if applicable), and the annual amount received from that source. Include any and all income sources that are listed below under Income Documentation. Please use the back of this page if you need additional space to complete your information. Name of Household Member Source of income Start date / End date Annual Income INCOME DOCUMENTATION: Total Annual Household Income: $ Please provide income documentation for each household member over the age of 18. Check all sources of income received during the last 2 years and provide copies of all items listed that pertain to your household. Income includes, but is not limited to, the sources listed below. If you do not have an item listed or are unsure of a requirement, please contact us. Tax returns: all pages of the most recent 2 years of filed and signed federal tax returns including all schedules, W-2s and/or 1099 s Employment: copies of the most recent 90 days of pay stubs, with year-to-date information, for all current jobs Social Security, disability or death benefits, pension, Public Assistance, or unemployment: Award Letter, annual letter or county disbursement from the provider stating amount and frequency Self-employment, ownership interest in corporation, partnership or business: most recent 2 years of filed and signed business tax returns, including K-1s and year-to-date Profit & Loss Statement, which includes business name and itemized earnings/expenses Alimony or child support: divorce decree or other written agreement filed with the court stating amount and period of time it will be received, as well as two most recent bank statements showing receipt of payments Rental Income: Income tax returns and/or lease agreement(s) documenting rental income Contract for Deed: Current Contract for Deed in its entirety, signed and dated, and twelve months of bank statements showing deposit of payment or cancelled checks showing receipt of payments
4 Roommate Rent: Rental agreement and twelve months bank statements showing receipt of rent payment Interest/Dividends: Most recent investment account statements Full-time students: Proof of full-time student status for household members age 18 and older (statement from institution with dates of attendance or specific reference to upcoming school term, and confirmation of full-time status) PLEASE ALSO INCLUDE THE FOLLOWING ITEMS, FOR YOUR APPLICATION: Our forms (Included with this packet. Please complete, sign and return.) Client/Co-Client: Home Improvement Intake Form, Homeowner s Self-Assessment Client/Co-Client: Borrower s Certification & Authorization, and Tennessen Warning: Notice of Rights For household members 18 & older who will not be on the loan: A Household Member Who is Not on the Promissory Note Certification & Authorization, Tennessen Warning: Notice of Rights Identification (Required for all household members 18 & older, as well as any owners that do not live in household.) Copy of current picture identification (i.e. driver s license or state ID, passport, permanent resident card (if applicable)) Bank Statements - required for all borrowers and spouses All pages of the most recent consecutive 2 months of actual bank statements for all checking and savings accounts Most recent money market, CD, Investment, bond, stock statement Mortgages Most recent monthly statement for every mortgage, home equity loan, grant and/or any other debt secured by your property For any other real estate owned, copy of most recent mortgage statement and property tax statement Insurance Homeowner s insurance declaration page (for all real estate owned), as well as agent s name and contact information Bankruptcy and foreclosures within the last 10 years Have you filed bankruptcy in the last 7 years? Yes No Had property foreclosed on in the last 10 years? Yes No If yes, please provide: Copy of bankruptcy discharge or Chapter 13 documents Copy of paperwork regarding foreclosures and / or short sales HOW DID YOU HEAR ABOUT US? (We want to know who to thank for sending you!) Previous client (who?) Word of mouth (who?) Newspaper (please specify) Other organization (which one?) Flyer (where did you see it?) Web search / internet (source?) *Please be advised: For your protection and privacy, we are unable to accept any documentation containing private information via e-mail. We suggest faxing, mailing, or dropping off your documents and information at one of our office locations.
5 I/We certify that the statements contained in this Intake Form are true, accurate and complete to the best of my/our knowledge and belief. Client: Name (print) Date Co-Client: Name (print) Date Complete by staff- Date received: By (print):
TENNESSEN WARNING: NOTICE OF RIGHTS: When you apply for a loan with Neighborhood Housing Services of Minneapolis (NHSM) private data requested in your application is legally required to determine if you qualify for the loan programs. Financial information, such as credit reports, financial statements and net worth calculations, are classified as private data on individuals by Minnesota Statutes Section 462A.065. All other data about you are classified as private data on individuals by Minnesota Statutes Section 13.462, except for your name, address, and amount of assistance you apply for or receive. You are not required to provide private data information, but if you refuse to provide it, we will be unable to determine your eligibility for these programs and approve your application(s). The information will be shared with CNHSM s staff, its loan servicers and contractors whose jobs require them to see it, and its successors. Where access to the data is authorized by state statute or federal law, it may be made available to others as so authorized. Your Social Security Number (SSN) is classified as private data by Minnesota Statutes Section 13.355, but if you do not disclose your SSN for the purposes described below, we will not approve your application. Your mortgage lender may require you to disclose your SSN so that it can comply with regulations that require it to report to you and the Internal Revenue Service the amount of mortgage interest payments you make. If you apply for a loan, disclosure of your SSN to NHSM is required by Title 42 of the United States Code, Section 405(c)(2)(C)(i), which permits the state to require disclosure of your social security number to establish your identity for purposes of administering tax laws of the state; and, Minnesota Statutes Sections 270A.01 to 270A.12 (the Revenue Recapture Act), which enables the state to collect delinquent debts owed to it by capturing tax refunds and other payments that you may otherwise be entitled. Section 270A.04, subdivisions 3 and 4, require the disclosure of a debtor s social security number for this purpose. NHSM may share your SSN with the Commissioner of the Minnesota Department of Revenue and the Minnesota Attorney General for the purposes of debt collection under the Revenue Recapture Act. Disclosure of your SSN to the NHSM is required to receive a Mortgage Credit Certificate (MCC). NHSM is required to report to the Internal Revenue Service information about individuals who have received an MCC, including their SSN, under Title 26 of the United States Code, Section 25(g), and Title 26, Code of Federal Regulations, Sections1.25-4T and 1.25-8T. Disclosure of your SSN for the purposes of verifying your income and credit is voluntary. However, if adequate verification of your income and credit cannot be determined without your SSN, we may be unable to determine your eligibility. The undersigned hereby acknowledge receiving and reading this disclosure. All household members 18 years old and older are required to sign and date.
TENNESSEN WARNING: NOTICE OF RIGHTS: When you apply for a loan with Community Neighborhood Housing Services, dba NeighborWorks Home Partners (NWHP) private data requested in your application is legally required to determine if you qualify for the loan programs. Financial information, such as credit reports, financial statements and net worth calculations, are classified as private data on individuals by Minnesota Statutes Section 462A.065. All other data about you are classified as private data on individuals by Minnesota Statutes Section 13.462, except for your name, address, and amount of assistance you apply for or receive. You are not required to provide private data information, but if you refuse to provide it, we will be unable to determine your eligibility for these programs and approve your application(s). The information will be shared with CNHS s staff, its loan servicers and contractors whose jobs require them to see it, and its successors. Where access to the data is authorized by state statute or federal law, it may be made available to others as so authorized. Your Social Security Number (SSN) is classified as private data by Minnesota Statutes Section 13.355, but if you do not disclose your SSN for the purposes described below, we will not approve your application. Your mortgage lender may require you to disclose your SSN so that it can comply with regulations that require it to report to you and the Internal Revenue Service the amount of mortgage interest payments you make. If you apply for a loan, disclosure of your SSN to NWHP is required by Title 42 of the United States Code, Section 405(c)(2)(C)(i), which permits the state to require disclosure of your social security number to establish your identity for purposes of administering tax laws of the state; and, Minnesota Statutes Sections 270A.01 to 270A.12 (the Revenue Recapture Act), which enables the state to collect delinquent debts owed to it by capturing tax refunds and other payments that you may otherwise be entitled. Section 270A.04, subdivisions 3 and 4, require the disclosure of a debtor s social security number for this purpose. CNHS may share your SSN with the Commissioner of the Minnesota Department of Revenue and the Minnesota Attorney General for the purposes of debt collection under the Revenue Recapture Act. Disclosure of your SSN to the NWHP is required to receive a Mortgage Credit Certificate (MCC). NWHP is required to report to the Internal Revenue Service information about individuals who have received an MCC, including their SSN, under Title 26 of the United States Code, Section 25(g), and Title 26, Code of Federal Regulations, Sections1.25-4T and 1.25-8T. Disclosure of your SSN for the purposes of verifying your income and credit is voluntary. However, if adequate verification of your income and credit cannot be determined without your SSN, we may be unable to determine your eligibility. The undersigned hereby acknowledge receiving and reading this disclosure and the Privacy Policy titled: What does Community NHS dba NeighborWorks Home Partners do with your personal information. All household members 18 years old and older are required to sign and date.