File Name: Customer-Intake-Form-2021.pdf
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1 STAFF USE: Appointment scheduled ______________________ Documents Given (Date) ______________________ If not; Pre-Adv. Action (Date): ____________________ Adv. Action Letter ______________________ (w/in 5 days of pre) SS entry _______________ (initial when complete) Updated 3/16/20 dj Customer Intake FormI am interested in housing in: (Mark one or both, if applicable) ____Bend ____ Redmond___ I have watched the Informational Videos on the website: Video Code 1: ______________ Video Code 2: ___________ (verification of review) This form is NOT considered an application for the housing program Along with this form please turn in 1-3 recent paystub copies or verification of income for each customerPRIMARY CUSTOMER INFORMATION Please Print ClearlyName: _____________________________________________________________________________________________________ First MI Last________________________________________________________________________________________________________________________ Street________________________________________________________________________________________________________________________ City State Zip CodePhone: (_____) _______–____________ Email: ___________________________________________________________________Ethnicity (please check one): ___ Hispanic/Latino ___ Non-Hispanic/LatinoRace (please check one): ___ American Indian or Alaska Native ___ Asian ___ Black or African American ___ Native Hawaiian or Other Pacific Islander ___ White ___ Other ___ 2 or more racesCitizenship (please select one):___ You are a Citizen or National of the United States___ You are foreign born and a U.S. Resident (green card holder)___ You are a Noncitizen with eligible status as evidenced by one of the documents listed below • Form I551-Alien Registration Receipt Card (for permanent resident aliens) • Form I-94, Arrival-departure record • A final court decision or DHS letter granting asylum___ None of the above – Not contending eligible immigration status, no further information required and the person named aboveunderstands they are not eligible for program selection but agrees to start housing counseling while immigration status changes
Marital Status (please select one): ___ Single ___ Married ___ Divorced ___ Separated ___ WidowedGender (please select one): ___ Male ___ Female ___ Other Gender Identity: (Optional) ______________________Education (please check one): ___ Below High School Diploma ___ High School Diploma or Equivalent ___ Two-Year College ___ Bachelors Degree ___ Masters Degree ___ Above Masters DegreeDo any of the following apply to you? Optional for data collection ___ Hearing difficulty (deaf or having serious difficulty hearing) ___ Vision Difficulty (blind or having serious difficulty seeing, even when wearing glasses) ___ Cognitive difficulty (Because of a physical, mental, or emotional problem, having difficulty remembering, concentrating, or making decisions) ___ Ambulatory difficulty (Having serious difficulty walking or climbing stairs) ___ Self-care difficulty (Having difficulty bathing or dressing) ___ Victim of Domestic Violence ___ Recovery from Substance Abusebendredmondhabitat.org 541.385.5387 224 NE Thurston Ave. Bend, OR 97701 2Are you a Veteran? ___ Yes ___ NoCurrent Housing Arrangement (please check one):___ Rent ___Homeless ___ Living with family member and not paying rent ___ Living with friends or roommates, sharing rentHealth InsuranceDo you currently have health insurance? If no, what prohibits you? ___ Yes ___ No ______________________________________________________________________________________________________First time BuyerDo you currently own a home, or have owned a home in the past three years? ___ Yes ___ NoHousehold Type (please select the most accurate)?___ Female headed single parent household ___ Male headed single parent household ___ Single adult___ Two or more unrelated adults ___ Married with children ___ Married without children ___ OtherFamily/Household Size: ______ (include those that will be living in the home for more than 6 months of the year)How many dependents (those claimed on taxes or legal guardian and other than those listed by any co-borrower)? ________What ages are they? ____,____,____,____,____,____,____,____,____Do all dependents have healthcare insurance? ___ Yes ___ No If no, please explain: _____________________________________________________________________________________Are there non-dependents who will be living in the home? ___ Yes ___ NoIf yes, list below:______________________________________________ ______________________________________________Relationship Age Relationship AgeNote: All adults over 18 years old, living in the household must submit financial documents so that we can calculate household incomelevels
Referred to by (please check all that apply): ___ Print Ad / Newspaper ___ Bank ___ Other Agency ___ Realtor ___ Facebook ___ Employer: ____________ ___ Staff/Board member ___ Walk-InFamily/Friend ___ TV /Radio ___ Other: _______________If you were referred by a Bank or Realtor, which one? _________________________________________________PRIMARY CUSTOMER EMPLOYMENT — Last 2 Years Please Print ClearlyPrimary Employer: ______________________________________________ Work Phone: (_______) _________–_______________________________________________________________ ____________________Title Hire Date___________________________________________________________________________________________________________Work Address Street City State Zip CodeEmployment Status (Please check one): ___ Part-Time ___ Full-Time Hours per pay period_____________________Gross monthly Income (before taxes): $____________________Are you paid (please check one) ___ Hourly: Amount per hour: __________ ___Salary: Amount p/month _______________ Is your hourly amount paid (please mark) ___weekly ___every two weeks ___twice a month ___monthlyIf applicable:Second Employer: ______________________________________________ Work Phone: (_______) _________–______________bendredmondhabitat.org 541.385.5387 224 NE Thurston Ave. Bend, OR 97701 3_________________________________________________ ____________________ (years, months)Title Length of Employment_______________________________________________________________________________________________Street City State Zip CodeEmployment Status (Please check one): ___ Part-Time ___ Full-Time Hours per pay period_____________________Gross monthly Income (before taxes): $____________________Are you paid (please check one) ___ Hourly: Amount per hour: __________ ___Salary: Amount p/month _______________ Is your hourly amount paid (please mark) ___weekly ___every two weeks ___twice a month ___monthlyPrevious Employer: _____________________________________________ Work Phone: (_______) _________–_______________________________________________________________ Length of Employment (dates) ____________________Title___________________________________________________________________________________________________________Street City State Zip Code___ Part-Time ___ Full-Time Hours per pay period_____________________Gross monthly Income (before taxes): $____________________Were you paid (please check one) ___ Hourly: Amount per hour: __________ ___Salary: Amount p/month _______________ Was your hourly amount paid (please mark) ___weekly ___every two weeks ___twice a month ___monthlyCO-APPLICANT INFORMATIONName: _____________________________________________________________________________________________________ First MI Last________________________________________________________________________________________________________________________ Street________________________________________________________________________________________________________________________ City State Zip CodePhone: (_____) _______–____________ Email: ___________________________________________________________________Ethnicity (please check one): ___ Hispanic/Latino ___ Non-Hispanic/LatinoRace (please check one): ___ American Indian or Alaska Native ___ Asian ___ Black or African American ___ Native Hawaiian or Other Pacific Islander ___ White ___ Other ___ 2 or more racesCitizenship (please select one):___ You are a Citizen or National of the United States___ You are foreign born and a U.S. Resident (green card holder)___ You are a Noncitizen with eligible status as evidenced by one of the documents listed below • Form I551-Alien Registration Receipt Card (for permanent resident aliens) • Form I-94, Arrival-departure record • A final court decision or DHS letter granting asylum___ None of the above – Not contending eligible immigration status, no further information required and the person named aboveunderstands they are not eligible for program selection but agrees to start housing counseling while immigration status changes
Marital Status (please select one): ___ Single ___ Married ___ Divorced ___ Separated ___ WidowedGender (please select one): ___ Male ___ Female ___ Other Gender Identity: (Optional) ______________________Education (please check one): ___ Below High School Diploma ___ High School Diploma or Equivalent ___ Two-Year College ___ Bachelors Degree ___ Masters Degree ___ Above Masters Degreebendredmondhabitat.org 541.385.5387 224 NE Thurston Ave. Bend, OR 97701 4 Do any of the following apply to you? Optional for data collection ___ Hearing difficulty (deaf or having serious difficulty hearing) ___ Vision Difficulty (blind or having serious difficulty seeing, even when wearing glasses) ___ Cognitive difficulty (Because of a physical, mental, or emotional problem, having difficulty remembering, concentrating, or making decisions) ___ Ambulatory difficulty (Having serious difficulty walking or climbing stairs) ___ Self-care difficulty (Having difficulty bathing or dressing) ___ Victim of Domestic Violence ___ Recovery from Substance AbuseAre you a Veteran? ___ Yes ___ NoRelationship to Customer (please check one): ___ Spouse/Partner ___ Daughter/Son ___ Sister/Brother ___Girlfriend/Boyfriend ___ Mother/Father ___ Other: _______________________________CO-APPLICANT EMPLOYMENT — Last 2 Years Please Print ClearlyPrimary Employer: ______________________________________________ Work Phone: (_______) _________–_______________________________________________________________ ____________________Title Hire Date___________________________________________________________________________________________________________Work Address Street City State Zip CodeEmployment Status (Please check one): ___ Part-Time ___ Full-Time Hours per pay period_____________________Gross monthly Income (before taxes): $____________________Are you paid (please check one) ___ Hourly: Amount per hour: __________ ___Salary: Amount p/month _______________ Is your hourly amount paid (please mark) ___weekly ___every two weeks ___twice a month ___monthlyIf applicable:Second Employer: ______________________________________________ Work Phone: (_______) _________–_______________________________________________________________ ____________________ (years, months)Title Length of Employment_______________________________________________________________________________________________Street City State Zip CodeEmployment Status (Please check one): ___ Part-Time ___ Full-Time Hours per pay period_____________________Gross monthly Income (before taxes): $____________________Are you paid (please check one) ___ Hourly: Amount per hour: __________ ___Salary: Amount p/month _______________ Is your hourly amount paid (please mark) ___weekly ___every two weeks ___twice a month ___monthlyPrevious Employer: _____________________________________________ Work Phone: (_______) _________–_______________________________________________________________ Length of Employment (dates) ____________________Title___________________________________________________________________________________________________________Street City State Zip Code___ Part-Time ___ Full-Time Hours per pay period_____________________Gross monthly Income (before taxes): $____________________bendredmondhabitat.org 541.385.5387 224 NE Thurston Ave. Bend, OR 97701 5Were you paid (please check one) ___ Hourly: Amount per hour: __________ ___Salary: Amount p/month _______________ Was your hourly amount paid (please mark) ___weekly ___every two weeks ___twice a month ___monthlyHOUSEHOLD INCOME Please Print ClearlyEstimated Gross Annual Family or Household Income: $______________ (include income from all adults – 18 and older – living in thehousehold)Type of Income (List ALL sources of income) BUYER CO-APPLICANT(s) Other Adult in Household Monthly Amount Monthly Amount Monthly Amount CO-APPLICANT(s)Salary, Wages (including Tips)Alimony/Child Support (children 16 and younger only)Rental IncomeSocial Security SSI / SSDI (children 16 and youngerand/or permanent disability only)Pension/ Retirement IncomePublic Assistance (Habitat does not use to calculate income)Self-employment IncomeDependent SSI Income (children 16 and younger and/orpermanent disability only)Other Employment (if employed for 2+ years)LIQUID FUNDS/SAVINGS/INVESTMENTS Please Print ClearlyPlease list the approximate value of the following: BUYER CO-APPLICANT(s) Other Adult inCO-APPLICANT(s) HouseholdChecking accountSavings accountChecking accountCashCDsSecurities (stocks, bonds, etc.)Retirement accountOther Liquid FundsHOUSING EXPENSES BUYER CO-APPLICANT(s) Other Adult inCO-APPLICANT(s) HouseholdCurrent monthly rentUtilities: Electric/Gas/Solid WasteTelephone / Cell phoneCable/Satellite TVInternetOther Living Expenses (ie.Storage)bendredmondhabitat.org 541.385.5387 224 NE Thurston Ave. Bend, OR 97701 6LIABILITIES / DEBT AUTHORIZATION TO RELEASE CREDIT INFORMATIONI authorize the Housing Counseling Staff of Bend-Redmond Habitat for Humanity to:(a) pull my/our credit report (soft pull; will not affect your score) 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 (soft pull) 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/We 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 liabilityand/or criminal liability under the provisions of Title 18, United States Code, Section 1001
_________________________________________________________ ____________________Customer Date_________________________________________________________ ____________________Co-Applicant DateSo that we my better counsel you, please complete the financial questionnaire
Please put an “x” in the column that best fits your current situation. As hard as it can sometimes be to think about moneyconcerns, this will give us an idea of how to best set goals together when we meet to review your mortgage readiness
How often does this happen to you? Often Sometimes Never1. Not enough money for essentials2. Behind on rent payments3. Don’t have enough food until there is more money4. Are in danger of having utilities turned off5. Unable to meet large bills6. Bills are confusing7. Excessive medical bills8. Behind in credit card payments9. Have had action taken by creditor10. Struggle to discuss finances with family or partner11. Bills get lost or mailed/paid late12. Feel stressed about finances13. Don’t know where money is going14. Not able to save 10% of income (each month)Other Yes NoChange in jobRecently divorced or separatedStruggle with some type of addictionOther:Other:What three things do you think are most important to pay first and regularly each month?1
What financial concern do you want to work on most?bendredmondhabitat.org 541.385.5387 224 NE Thurston Ave. Bend, OR 97701
Customer Intake Form . I am interested in housing in: ____Bend ____ Redmond ___ I have watched the Informational Videos on the website: Video Code 1: _____ Video Code 2: _____ …
A client intake form is a questionnaire that you share with a client at the beginning of a working relationship. With a new client intake form, you can gather the information you need from a client so that you can: Understand if the client is a good fit for your company.
This universal template accommodates a wide range of business purposes; use it for single client intake or as a template to record multiple clients’ information upon initial contact. You can store this new client information securely or share it with fellow employees and departments in order to keep everyone apprised of new client details.
Publicly, by sharing the form on your website. Privately, by sending the form to your prospects or new clients. 1. Using a website client intake form Uploading your client intake form on your website may drive a higher intake.
The template has space for you to write down the personal information of the client, citation data, payment records, and other relevant information. With easy-to-fill and comprehensive counseling intake form templates, you can track crucial client details before their first counseling sessions.