CUSTOMER INTAKE FORM HOMEOWNERSHIP COUNSELING PROGRAM CUSTOMER please print clearly Name: First MI Last Address: Home: ( ) - Work: ( ) - Email: Fax: ( ) - Mobile/Cell: ( ) - Social Security Number: - - Birth : / / Race (please circle): 1. White 5. Native Hawaiian/Other Pacific Islander 9. American Indian/Alaskan Native and Black 2. Black or African American 6. American Indian/Alaskan Native and White 10. Other 3. American Indian/Alaskan Native 7. Asian and White 4. Asian 8. Black/African American and White Ethnicity: Please select yes or no for Hispanic origin. You should select both a Race category and a yes or no for Hispanic origin. Hispanic: Yes No Immigrant Status (please circle): 1. You are U.S. born and one or both of your parents are foreign born 2. You are U.S. born but one or both grandparents foreign born 3. You are foreign born 4. You, your parents, and grandparents are all U.S. born Marital Status (please circle): Single Married Divorced Widowed Gender (please circle): Male Female Disabled? (please circle): Yes No Current Housing Arrangement (please circle): 1. Rent 4. Living with family member 2. Homeless 5. Homeowner with mortgage paid off 3. Homeowner with mortgage Are you a first-time buyer (you do not currently own a home and have not owned a home in the past three years)? Yes No Household Type (please select the most accurate): 1. Female headed single-parent household 3. Single adult 5. Married with children 7. Other 2. Male headed single-parent household 4. Two or more unrelated adults 6. Married without children 1
Household Size: Dependent Name Age Relationship to Client Annual Household Income: $ Education (please circle): 1. Below High School Diploma 4. Bachelor s Degree 2. High School Diploma or Equivalent 5. Master s Degree 3. Associate s Degree 6. Above Master s Degree Referred to by (please circle all that apply): Print Advertisement Bank TV Realtor Habitat Homeowner Staff/Board Member Walk-In Friend Radio Newspaper Article If you were referred by a bank, which one? If referred by another source not listed above, which one? CO-APPLICANT please print clearly Name: First MI Last Address: Home: ( ) - Work: ( ) - Email: Fax: ( ) - Mobile/Cell: ( ) - Social Security Number: - - Birth : / / Race (please circle): 1. White 5. Native Hawaiian/Other Pacific Islander 9. American Indian/Alaskan Native and Black 2. Black or African American 6. American Indian/Alaskan Native and White 10. Other 3. American Indian/Alaskan Native 7. Asian and White 4. Asian 8. Black/African American and White Ethnicity: Please select yes or no for Hispanic origin. You should select both a Race category and a yes or no for Hispanic origin. Hispanic: Yes No Immigrant Status (please circle): 1. You are U.S. born and one or both of your parents are foreign born 2. You are U.S. born but one or both grandparents foreign born 3. You are foreign born 4. You, your parents, and grandparents are all U.S. born 2
Marital Status (please circle): Single Married Divorced Widowed Gender (please circle): Male Female Disabled? (please circle): Yes No Education (please circle): 1. Below High School Diploma 4. Bachelor s Degree 2. High School Diploma or Equivalent 5. Master s Degree 3. Associate s Degree 6. Above Master s Degree Relationship to Customer (please circle): Son Father Brother Boyfriend Spouse Daughter Mother Sister Girlfriend Other: CUSTOMER EMPLOYMENT last 2 years please print clearly Primary Employer: Title Hire Address: Hourly Rate of Pay: $ Pay Frequency weekly every 2 weeks twice a month monthly Secondary Employer: Title Hire Address: Hourly Rate of Pay: $ Pay Frequency weekly every 2 weeks twice a month monthly Previous Employer: Title Hire End Address: Hourly Rate of Pay: $ Pay Frequency weekly every 2 weeks twice a month monthly 3
CO-APPLICANT EMPLOYMENT last 2 years please print clearly Primary Employer: Title Hire Address: Hourly Rate of Pay: $ Pay Frequency weekly every 2 weeks twice a month monthly Secondary Employer: Title Hire Address: Hourly Rate of Pay: $ Pay Frequency weekly every 2 weeks twice a month monthly Previous Employer: Title Hire End Address: Hourly Rate of Pay: $ Pay Frequency weekly every 2 weeks twice a month monthly 4
INCOME please print clearly CUSTOMER CO-APPLICANT Type of Income Monthly Amount Monthly Amount Salary Alimony/Child Support (Recieved) Rental Income Social Security or Retirement Income Pension Income Public Assistance Self-Employment Income Dependent SSI Income Disability Income or SSI for applicants Other Employment CUSTOMER CO-APPLICANT Can you document your child support/alimony income? Yes No N/A Yes No N/A If yes, how long will it continue? If your child is under 13 or a family member receives SSI, how many more years will the payments continue? N/A N/A If you receive disability income, is it for a permanent disability? Yes No N/A Yes No N/A Regarding secondary employment, have you worked in this field for two years or more? Yes No N/A Yes No N/A ADDITIONAL INFORMATION CUSTOMER CO-APPLICANT Have you owned a home in the last three (3) years? Are you a veteran? Do you have a contract on a house at this time? Are you currently working with a real-estate agent? If so, please specify agent's name: Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Most convenient time for an individual appointment? Have you attended an orientation session? If yes, please specify date: a.m. Yes No p.m. Yes No If yes, please specify location: 5
AUTHORIZATION I authorize the Housing Counseling Agency to: (a) pull my/our credit report to review my/our credit file for housing counseling in connection with my pursuit on a loan to purchase real property; (b) pull my/our credit report and review my/our credit file for informational inquiry purposes; and (c) obtain a copy of the HUD-1 Settlement Statement, Appraisal, and Real Estate Note(s) when I purchase a home, from the lender who made me/us a loan and/or the title company that closed the loan. I/we understand that any intentional or negligent representation(s) of the information contained on this form may result in civil liability and/or criminal liability under the provisions of Title 18, United States Code, Section 1001. Customer Co-Applicant 6
I acknowledge that I am working with Dallas Area Habitat for Humanity on issues related to a mortgage loan. I hereby authorize Dallas Area Habitat for Humanity, Inc. to verify my past and present employment earnings records, bank accounts, stock holdings, and any other asset balances as needed to assist me with my issues related to a mortgage loan. I further authorize Dallas Area Habitat for Humanity to order a credit report and verify other credit information, including past and present mortgage and landlord references. I hereby authorize third parties to release information to Dallas Area Habitat for Humanity concerning employment histories, dates, title, income, hours worked, banking and saving accounts, mortgage loan information, rental verification (including opening dates, payment amounts, and payment records), other information Dallas Area Habitat for Humanity deems necessary to verify the above-mentioned information and a credit report. I understand that all information obtained by Dallas Area Habitat for Humanity will be used to verify the information I have supplied to Dallas Area Habitat for Humanity and to help me with the issues related to the mortgage loan. I understand that the information obtained by Dallas Area Habitat for Humanity may be disclosed to lender agencies if such disclosure would assist me with my mortgage loan and I hereby authorize such disclosures. I acknowledge that, outside of the disclosures described above, the information obtained will be kept confidential. I hereby authorize Dallas Area Habitat for Humanity to discuss my issues related to a mortgage loan with my lender. I also authorize my lender to provide Dallas Area Habitat for Humanity with a copy of any information the lender may have that will assist me with the issues related to my mortgage loan, including but not limited to: a copy of my mortgage application, a recent mortgage statement, and appraisal(s). A photographic, facsimile or emailed copy of this signed authorization shall be as valid and as effective as the original signed authorization. Borrower Printed Name Borrower Signature Co-Borrower Printed Name Co-Borrower Signature 2800 N. Hampton Rd. Dallas, TX 75212 214.678.2300 dallasareahabitat.org @dallashabitat #BuildaBetterDallas
Dallas Area Habitat for Humanity understands that high-quality homeownership education provides borrowers with the information and resources they need to navigate the home buying process and make informed decisions. As a one-stop homeownership center, Dallas Habitat provides members with pre- and post-purchase counseling, as well as homebuyer education courses to equip borrowers with the knowledge that will help them to succeed as future homeowners. As a member, borrowers receive: ongoing, one-on-one homeownership counseling, pre-purchase education training (including money management/credit building/quality of life classes and materials and Homebuyer Education class and manual), and post-purchase counseling. Additionally, members have access to our preferred REALTOR network and partner lenders. The membership fee for counseling and educational services is $125 for single borrowers and $200 for dual borrowers*. Paid membership fees will be non-refundable and acceptable payment methods include money order, cashier s check and debit card. Cash and credit cards are not accepted. *All fees are subject to change 2800 N. Hampton Rd. Dallas, TX 75212 214.678.2300 dallasareahabitat.org @dallashabitat #BuildaBetterDallas
I/We understand that the purpose of the housing counseling program is to provide one-on-one counseling to help customers fix those problems that prevent affordable mortgage financing. The counselor will analyze my/our financial and credit situation, identify those barriers preventing me/us from obtaining affordable mortgage financing, and develop a plan to remove those barriers. The counselor will also provide assistance in debt-load management with the preparation of a monthly and manageable budget plan. I/We further understand that it will not be the responsibility of the counselor to fix the problem for me/us but rather to provide guidance and education to empower me/us in fixing those issues preventing affordable mortgage financing. Upon completion of the housing counseling program, I/we understand that the counselor will help to identify those loan programs that best my/our needs and choose a lender that is right for me/us. Upon completion of the program, and with my/our permission, my/our customer information will be transferred to my/our selected lender. I/We understand that the counselor will monitor my/our loan progress to ensure the loan process runs smoothly and provide assistance as needed. I/We understand that the counseling agency does not guarantee that I/we will receive mortgage financing from the chosen lender. I/We understand that the counseling agency provides housing counseling assistance to customers whose problems can be resolved in 24 months or less. I/We understand that if it is determined my/our issues will take longer than 24 months to fix, I will be referred to a long-term housing counseling program. I/We understand that as part of the housing counseling program, I/we will be required to attend group homeownership education classes. I/We understand that it is our responsibility to work in conjunction with the counseling process and that failure to cooperate will result in the discontinuation of my counseling program. This includes but is not limited to missing three consecutive appointments. Customer s Signature Co-Applicant s Signature Source: INHP Pre-Purchase Counseling Manual by Indianapolis Neighborhood Housing Partnership. 2800 N. Hampton Rd. Dallas, TX 75212 214.678.2300 dallasareahabitat.org @dallashabitat #BuildaBetterDallas
The following disclosure and acknowledgment apply to those transactions in which the real estate agent/broker representing the seller and the housing counselor consulting with you are employed by the same entity. We wish to explain what dual agency means to you. As a real estate licensee, the agency sells residential real property owned by the agency. In this capacity, the agency s primary responsibility is to itself as the seller of real property. As a counselor, the agency counsels you in preparing for homeownership. In this capacity, the agency s primary responsibility is to you. You are not obligated to purchase residential real property owned by the agency or obtain financing from Dallas Neighborhood Homes as a condition of receiving counseling services from the agency. By making this disclosure, the agency wishes to obtain your informed consent to operate in a dual agency capacity. By consenting to dual agency, you are giving up your right to undivided loyalty. You should carefully consider the possible consequences of a dual agency relationship before agreeing to such representation. You may retain the services of a real estate agent/broker or a counselor who will represent only your interest in the transaction. Since the agency is not a legal expert or an attorney, you may wish to consult an attorney before signing this form. By signing below, you acknowledge that you have received and read this disclosure notice. You also acknowledge that you understand that as a real estate agent/broker the agency may be acting in its own best interests relative to the sale of residential real property owned by the agency. Finally, by signing below, you consent to the dual agency. Print Name Print Name Signature Signature 2800 N. Hampton Rd. Dallas, TX 75212 214.678.2300 dallasareahabitat.org @dallashabitat #BuildaBetterDallas