Homeownership Program Customer Intake Form Date

Summary

Homeownership Program Customer Intake Form
Date: _____/_____/______
Customer Number: ____________________
CUSTOMER Please Print Clearly
Name:_________________________________________________________________
First MI Last
Address:_________________________________________________________________________
_____________________________________________________________________________
City County State Zip Code
Home: ( )________-_________ Work: ( )_________-_______ Email:_________________
Best Time to reach you:_____________________ Yrs. At this address________
____________-______-_________ _________/__________/_________
Social Security Number Birth Date
Race (please circle):
(1) Black or African American (2) White (3) American Indian/ Alaskan Native (4) Asian
(5) Native Hawaiian/ Other Pacific (6) American Indian/ Alaskan Native and Black
(7) American Indian/ Alaskan Native and White (8) Black/ African American/ White
(9) Asian & White (10) Other
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
Marital Status (please circle): Unmarried Married Divorced Separated Widowed
Gender (please circle): Male Female Handicapped (please circle): Yes No
U.S. Military Veteran: Yes No
1
Current Housing Arrangement (please circle):
(1) Rent (2) Rent with Section 8 (3) Rent with Public/ Subsidized Housing (4) Homeless
(5) Homeowner with mortgage (6) Living with family member and not paying rent (7) Homeowner
with mortgage paid off
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 2. Male headed single parent household
3. Single adult 4. Two or more unrelated adults 5. Married with children
6. Married without children 7. Other
Family/ Household Size:_____ How many dependents(other than those listed by any co-
borrower)?________
What ages are they? ____,____,___,____,____,____,____,_____,_____
Education (please circle one)
(1) Below High School Diploma (2) High School Diploma or Equivalent
(2) Two Year College (4) Bachelor Degree (5) Master’s Degree (6) Above Master’s Degree
Referred to by (please circle all that apply):
Print Advertisement Bank/Lender Government Realtor Urban League Staff/ Board member Walk- In
Friend/ Relative Radio
If you were referred by a bank, which one? _______________________
If you were referred by another source not listed above, which one? ______________________
2
CO-APPLICANT
Name:_________________________________________________________________
First MI Last
Address:_________________________________________________________________________
_____________________________________________________________________________
City County State Zip Code
Home: ( )________-_________ Work: ( )_________-_______ Email:_________________
Yrs. At this address_____
____________-______-_________ _________/__________/_________
Social Security Number Birth Date
Race (please circle):
(2) Black or African American (2) White (3) American Indian/ Alaskan Native (4) Asian
(5) Native Hawaiian/ Other Pacific (6) American Indian/ Alaskan Native and Black
(7) American Indian/ Alaskan Native and White (8) Black/ African American/ White
(9) Asian & White (10) Other
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
Marital Status (please circle): Unmarried Married Divorced Separated Widowed
Gender (please circle): Male Female Handicapped (please circle): Yes No
U.S. Military Veteran Yes No
Education (please circle one)
(3) Below High School Diploma (2) High School Diploma or Equivalent
(4) Two Year College (4) Bachelor Degree (5) Master’s Degree (6) Above Master’s Degree
Relationship to Customer (please circle): Spouse Daughter Son Sister Brother Girlfriend
Boyfriend Mother Father Other:_________________________________
3
CUSTOMER EMPLOYMENT- Last 2 Years
Primary Employer: _____________________________________________________________
__________________________________________________ __________________________
Title Hire Date (mm/dd/yy)
____________________________________________________________________________________
Street City State Zip Code
Phone: ( ) _________-__________
Part time or Full time (Circle one)
Gross Income (before taxes): $______________________ Yearly/ Annual______________
Is the amount paid __hourly ____weekly ____ every two weeks ____ twice a month
___ monthly?
Secondary Employer (if applicable)_______________________________________________
__________________________________________________ __________________________
Title Hire Date (mm/dd/yy)
____________________________________________________________________________________
Street City State Zip Code
Phone: ( ) _________-__________
Part time or Full time (Circle one)
Gross Income (before taxes): $______________________
Is the amount paid __hourly ____weekly ____ every two weeks ____ twice a month
___ monthly?
CO- APPLICANT EMPLOYEMNT – Last 2 Years
Primary Employer: _____________________________________________________________
__________________________________________________ __________________________
Title Hire Date (mm/dd/yy)
____________________________________________________________________________________
Street City State Zip Code
Phone: ( ) _________-__________
Part time or Full time (Circle one)
Gross Income (before taxes): $______________________
4
Is the amount paid __hourly ____weekly ____ every two weeks ____ twice a month
___ monthly?
Secondary Employer (if applicable)_______________________________________________
__________________________________________________ __________________________
Title Hire Date (mm/dd/yy)
____________________________________________________________________________________
Street City State Zip Code
Phone: ( ) _________-__________
Part time or Full time (Circle one)
Gross Income (before taxes): $______________________
Is the amount paid __hourly ____weekly ____ every two weeks ____ twice a month
___ monthly?
INCOME Please Print Clearly
Type of Income Customer Monthly Amount Co –Applicant Monthly Amount
Salary
Alimony/ Child Support
Rental Income
Social Security
Pension Income
Self- employment Income
Public Assistance
Dependent SSI Income
Disability Income
Other
Customer Co- Applicant
Can you document your child support/ alimony income? ___ Yes ___No ___Yes ___No
If yes, How long will it continue? ________ ________
If your child or a family member receives SSI

how many more years will the payment continue ? ________ _________
If you receive disability income, is it for a
permanent disability? ____Yes ___No ___Yes ___No
Regarding other employment, have you worked
in this field for two years or more? ___Yes ___No ___Yes ___No
5
LIABILITIES/DEBT
Please list any debts you have, including credit cards, auto loans, and child-care expenses. DO NOT include rent or
utilities

Who’s Debt?
C=Customer
A= Co- Applicant
Paid To Current Balance Monthly Payment B= Both
CUSTOMER CO- APPLICANT
Have your payments been made on time? ___Yes ____No ____Yes ____No
Are you currently in Chapter 13 bankruptcy? ____Yes ____No ____Yes ____No
If yes, when did it begin?_____________
If yes, when will it paid out?__________
If yes, how much is the payment?______
Have you has a Chapter 7 bankruptcy? ____Yes ____No ____Yes _____No
If yes, when was it discharged? ______________
6
LIQUID FUNDS/ SAVINGS/INVESTMENT Please Print Clearly
Please list the approximate value of the following
CUSTOMER CO-APPLICANT
Checking account
Savings account
Cash
CD’s
Securities (stocks, bonds, etc.)
Retirement account
Other Liquid Funds
Are you about to receive additional funds (e.g., tax refunds, property sales, etc.)? ___Yes ___No
If yes, how much? $___________________
LIVING EXPENSES
CUSTOMER CO-APLICANT
Current monthly rent or mortgage
Electric/ Gas/ Water/ Solid Waste
Telephone
Cellular/ Pager
Cable/ Satellite TV
Food
Personal care
Transportation (bus, fares, gas for car,
etc.)
Other expenses
ADDITIONAL INFORMATION
CUSTOMER CO-APPLICANT
Have you owned a home in the last three (3) years? ___Yes ___No ____Yes ____No
Are you a Veteran? ____Yes ___No ____Yes ____No
Do you have a contract on a house at this time? ____Yes ___No
Are you currently working with a real estate agent? ____Yes ___No
Most convenient time for an individual appointment? ________ AM _________PM
7
AUTHORIZATION
I authorize the Urban League of Greater Pittsburgh to:
(a) Pull my/our credit report to review my/ our credit file for housing counseling in connection with
my pursuit on 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 form 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 the civil liability
and/or criminal liability under the provision of Title 185, United State Code, Section 1001

_______________________________________ __________________
Customer Date
_______________________________________ __________________
Co-Applicant Date
8
Authorization, Disclosure, Privacy Statement (3-in-1)
COUNSELING SERVICES AUTHORIZATION
My personal information and counseling services
By signing this form I agree to share my personal financial and other private information. Signing this form also allows
lenders and the Counseling Agency to discuss my accounts, credit, and finances, and to share my nonpublic personal
information, described in the Privacy Policy provided with this authorization

I understand that funders provide grants to make the counseling services possible, and that the Counseling Agency
shares my information with these funders. These funders review Counseling Agency files, including my file, and may
contact me to evaluate the counseling services that I receive

I authorize my Counselor and the Counseling Agency to negotiate for me. The counseling services are offered free of
charge, and neither the Counselor, nor the Counseling Agency, guarantees any result or outcome. I may be referred to
other housing agencies for their services. I am not obligated to accept services or products from the Counseling Agency,
its partners, or any organization I am referred to

I understand that my Counselor cannot offer me legal or other professional advice or representation. If I need legal or
other professional services I can ask my Counselor for information about referral services

Counseling Services Checklist
Client must initial all items that are applicable
I have been verbally advised of the fee schedule, if any, prior to services being provided
I have discussed Home Buyer Options and related Pre-Purchase topics and I have received the HUD forms:
“Ten Important Questions to Ask Your Home Inspector” & “For Your Protection: Get a Home Inspection”
I have received and reviewed a copy of the Fair Housing Pamphlet
I understand that the counselor will discuss my budget with me and I will receive a copy of my Budget
I understand that the counselor will discuss my Action Plan with me and I will receive a copy of my Action Plan
I understand the counselor will explain the next steps needed to reach my financial goal to my satisfaction
Homebuyer Counseling Homebuyer Education
Homeowner Counseling Homeowner Education
Delinquency and Default Counseling Delinquency and Default Education
Reverse Mortgage Counseling Fair Housing Education
Tenant Counseling Homelessness and Displacement Counseling
I want to buy a home in the next six (6) months
I want to buy a home, but not in the next six (6) months
Other programs, services, or products:
Counseling Agency Information
Counselor Name: Phone:
Counseling Agency: Email:
RX Client Number: Fax:
211 N. Front St. PO Box 8029 Harrisburg, Pennsylvania 17105 P a g e |1 - 1
717.780.3800 Fax 717.780.1897 TTY 717.780.1869 www.phfa.org
PENNSYLVANIA HOUSING FINANCE AGENCY 3_in_1 Form 04-18 front
Authorization, Disclosure, Privacy Statement (3-in-1)
PRIVACY POLICY
This Counseling Agency respects the privacy of the people that come to us for assistance. We understand that the
matters you discuss with us are very personal. All spoken and written information shared with us will be managed with
our legal and ethical obligations to you taken into consideration. We will not sell your personal information and we
only share it to provide you with counseling services

Your “nonpublic personal information” (including total debt information, income, living expenses, and personal
information concerning your financial circumstances) will be shared with creditors, funders, and others only after you
sign the Counseling Services Authorization. We may also collect, use, and share anonymous aggregated case file
information to evaluate our services, to gather valuable research information, and to design future programs

Types of Information That We Gather About You:
 Spoken or written information on applications and other documents, such as your name, address, social
security number, assets, and income;
 Information about your transactions with us, your creditors, or others, such as your account balance, payment
history, parties to transactions and credit card usage; and
 Information we receive from a credit reporting agency, such as your credit history

You May Opt-Out If You Do Not Want Us to Share Your Information:
 You may "opt-out" to prevent the disclosure of your nonpublic personal information to third parties (such as
your creditors)

 If you opt-out we cannot share your nonpublic information and we cannot answer questions from your
creditors. We need to share your information to provide you with most services

 You may opt-out at any time by calling the Counseling Agency at the phone number listed on the Counseling
Services Authorization provided with this Privacy Policy

How We Use Your Information:
 If you do not opt-out we may share information that we collect about you with your creditors or others if we
think it would be helpful to you, would help us counsel you, or when required by funders that make our
services possible

 We may share information about you to anyone as permitted or as required by law (e.g., if a Court requires us
to provide it with documents)

 Within our organization, we restrict access to your information to those employees who need to know that
information to provide services to you. We maintain physical, electronic, and procedural safeguards to protect
your information as required by federal and state law

Client Authorization
By signing below I authorize my employers, lenders, creditors, servicers, and others to share personal and
financial information with my Counselor and the Counseling Agency. I authorize my Counselor and the Counseling
Agency to collect information about my accounts and to share this information with others, including funders, as
needed to provide counseling services, to seek assistance from programs, or for related products and services. I
authorize funders to contact me to evaluate programs that I participate in

CLIENT NAME(S): CLIENT SIGNATURE(S): DATE:
1

211 N. Front St. PO Box 8029 Harrisburg, Pennsylvania 17105 P a g e |1 - 2
717.780.3800 Fax 717.780.1897 TTY 717.780.1869 www.phfa.org
PENNSYLVANIA HOUSING FINANCE AGENCY 3_in_1 Form 04-18 back
211 N. Front St

7 1 7 . 7 8 0. 3 8 0 0
PENNSYLVANIA HOUSING FINANCE AGENCY
ARE YOU READY TO BE A HOMEOWNER?
SELF ASSESSMENT TOOL
1. Being in debt does not bother me. Yes_____ No_____
2. The thought of having long-term debt is Yes_____ No_____
disturbing to me

3. I enjoy working around the house and Yes _____ No _____
yard

4. I would much rather shop, go out to eat, or Yes _____ No_____
read a book then spend any time around
the house or yard

5. I prefer finding a good job and staying Yes_____ No_____
with it

6. I prefer changing jobs from time to time, Yes_____ No_____
finding excitement in starting all over

7. I prefer staying in one place and being Yes _____ No _____
committed to one community

8. I do not like being limited to one Yes_____ No_____
community or location for a long period of
time

9. I am able to handle the financial Yes_____ No_____
responsibilities of mortgage payments
now

10. I would be better off waiting until I can Yes_____ No _____
save more money or my financial situation
improves

OTHER QUESTIONS TO HELP YOU MAKE THE HOME BUYING DECISION
1. Is owning a home important to you? Yes_____ No_____
2. Are you currently renting a home or Home________ Apartment_______
apartment? Other________
3. Are you paying your rent on time? Yes_____ No_____
4. Do you have any outstanding debt? Yes _____ No_____
5. Are you paying this debt on time? Yes_____ No_____
6. Do you have any forms of credit? Yes_____ No_____
7. Do you have a bank account? Yes _____ No_____
8. Do you have a checking account? Yes______ No_____
9. Are you responsible for your utilities? Yes ______No_____
10. Do you pay your utility bill on time? Yes______ No_____
11. How is your credit? Good______ Bad______ Ok_______
211 N. Front St

717.780.3800
PENNSYLVANIA HOUSING FINANCE AGENCY
MORTGAGE QUALIFICATIONS & OTHER CONSIDERATIONS:
Credit Report Gross Monthly First Time Home Buyer Yes______
Score____________ Income____________ No______
Years of Net Monthly County of
Employment____________ Income______________ Interest_______________________
Yearly Gross Current Monthly Expenses Purchase Price____________
Income____________ ___________
Average Yearly Current Monthly Home of Interest : Existing Home ____
Overtime___________ Rent_________ New Home _______
Cash Reserves
Available__________ Monthly Section 8 Voucher Monthly Child Support Payment
Securities, Mutual Funds, Income _________ _________
Stocks__________ Court Ordered Yes _______
No________
Monthly Social Security, Number of persons in Number of Children in
Disability, Public Assistance Household_______ Household__________
Income__________
Front End Ratio Limits _________
Are you living with persons who Are you disabled? Back end Ratio Limits__________
are disabled Yes _______ No________
Yes _______ No________
Name:_________________________________
Address: ________________________City:______________ State: _________ Zip:
_________Telephone: (Day) ____________ (Evening) _________________
(For Official Use Only)
Based on information provided, above client is:
(Check one) ______ PHFA Potential Candidate
______ Presenting Credit Issues
Appointment (Day & Date) ______________________Time:_______AM________PM
Counselor Assigned_________________________________

Purchase a home form 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 …

Download Now

Documemt Updated

Popular Download

• › Homeownership Program Customer Intake Form Date
• › How To Submit A Service Desk Ticket Savannah State
• › How To Fill Out The I 9 Page 2 Authorized
• › Home Health Aide Duty Sheet Bluelinehccom
• › High School Graphic Design Textbook Davis Art
• › How To Write A Research Briefing University Of
• › How To Create A Legacy Society Brochure
• › High Density Polyethylene Jm Eagle
• › Helping Shape The Future Of Worklife Staples Inc
• › Highly Effective School Library Program Action Plan
• › Healthy Start City Of Philadelphia
• › Hipaa Employee Confidentiality Agreement Eforms
• › How To Organise Plan And Control Projects Govuk
• › How To Use Google Docs Resume Templates Putnam
• › Home School Brochure Wilmington Christian
• › Healthy Children Children See Adults As Role Models Even At
• › Ho W T O Ma K E A Pu Rc H A S E O Rde R U S I N G Te M
• › Hate Crime Brochure Template Attorney General Of
• › Hsbcs Red Mastercard Rewards Catalogue
• › How To Create Business Cards Manually In Wordperfect

Frequently Asked Questions

What are the requirements of the phas homeownership program?

The PHA's homeownership program also must contain a written agreement and the applicable legal documentation that specifies the respective rights and obligations of the PHA and the PRE. Affordability standards must be met for the purchaser.

Can a pha use section 32 homeownership program proceeds?

Therefore, PHAs are only permitted to use Section 32 homeownership program proceeds in connection with public housing units under an ACC, housing assisted by the Housing Choice Voucher Program, or to fund a homeownership plan under the Act.

How do i prepare a homeownership plan under section 32?

The specific requirements for preparing a homeownership plan under Section 32 are set out in the Section 32 Desk Guide, the Inventory Removals Application (HUD-52860), the Homeownership Addendum (or Homeownership Term Sheet) to that Application (HUD-52860-C), and the tools available for download below.

How can public housing agencies phas further affordable homeownership?

On February 9, 2022, HUD held a webinar explaining how Public Housing Agencies (PHAs) can further affordable homeownership in their communities through federal housing programs and assistance. See the video and presentation materials here. The final rule for Section 32 Homeownership was published March 11, 2003, and became effective April 10, 2003.