Housing Counseling

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Housing Counseling

Housing Counseling Intake Form

Application for Housing Counseling Services

Part One: Biographic and Demographic Info
Primary Applicant*
Last, First, Middle
Address*
Address and Apartment #, City, State, Zip Code
Email Address*
Email Address
Contact Number*
Mobile, Home, Work
Best Time To Reach You
Preferred Contact Method
Date of Birth*
Gender*
Race*
Ethnicity*
Languages Spoken
Specify primary and or secondary language spoken.
Are you a Veteran?*
Are you Disabled?*
Special Needs (eg. Interpreter/Translation Service, Wheel Chair Access )
Highest Education Level Attempted
Marital Status*
Household Type*
Family Household Size*
Number of people living in the household.
Household Members*
Name Age Gender (M/F) Relationship Dependent (Y/N)

All parties living in the household
Part Two: Employment Status Info
Last 2 years
Employer 1 Name*
First
Employer 1 Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer 1 Phone Number*
Dates of Employment (From - To)*
Date Format: MM slash DD slash YYYY

(Start date-End Date )
Previous Employer Name
First
Previous Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Previous Employer Phone
Dates of Employment (From - To)
Date Format: MM slash DD slash YYYY

(Start Date-End Date)
Part Three: Housing Status and Housing Goals
My Current Housing Status Is:*
- Renting/Leasing
- Homeowner with Mortgage
- Homeowner with no Mortgage Debt
- Living with Family
- Homeless
- Other
My Current Housing Goal Is:*
- Buy A Home (Pre-Purchase Counseling)
- Prevent Foreclosure (DFC)
- Obtaining Rental Housing (RHC)
- Transition from Homelessness
- Obtain a Reverse Mortgage
- Credit and Budget Counseling (FBC)
- Fair Housing (FHW)
- Home Improvement and Rehab (HIC)
- Other HCA Services
Part Four: Rental or Mortgage Info
If you are renting, How long have you been renting? Years, Months*
Check All That Apply
- I Pay Market Rent
- I receive rent subsidy and/or public housing resident
- I am a Section 8 recipient
- I am facing eviction
- I am delinquent with my rent and need assistance
- I am delinquent with my utilities and need assistance
- I am interested in filing a fair housing claim
- Other
If you own your property answer the following Section.
Do you have a mortgage? If so answer the following questions.*
Is this loan Current or Delinquent?
Mortgage Servicer Name
Loan Number
Loan Balance
Interest Rate
Principal and Interest Rate (Including Taxes and Insurance)
Private Mortgage Insurance (PMI)
Fixed or Adjusted Interest Rate
Date of last payment.
Past Due Amount.
Have you previously applied for a loan modification or forbearance? If yes please provide details on the outcome of your previous prevention efforts.
Has your hardship ended? Yes or No
Do you have the ability and willingness to resume mortgage payments? If "NO", are you seeking and alternative outcome such as Deed-in-Lieu of Foreclosure or Short Sale? Explain.
Part Five: Credit, Income, Debt and Monthly Expenses
Salary/Wages*
Monthly
Rental Income
Monthly
Child Support
Monthly
Social Security
Monthly
Disability Income
Monthly
Unemployment Income
Monthly
Pension
Monthly
Public Assistance Income
Monthly
Other Income
Monthly
Tot. Combined Gross Income:
Debt
Monthly
Rent
Mortgage (Principal & Interest)
Property Taxes, HOA, Insurance
Car Payment
Car Insurance
Credit Cards (Tot)
Childcare/Daycare
Child Support/Alimony
(Amount Paid)
Personal Loans
School Loans
Medical Debt
(Tot. of current medical bills)
Gas/Transportation
Household Utilities
(Electric, Water, Gas, Cable, Internet (wifi)
Cell Phone
Food
Tithing
Misc
Total Monthly Debt

The Housing Counseling Program provides first-time home-buyer classes and individual counseling sessions, mortgage delinquency & default resolution counseling, financial management/budget counseling and Georgia Dream Down Payment Assistance to help families improve their credit.

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Name	Age	Gender (M/F)	Relationship	Dependent (Y/N)

Housing Counseling

Housing Counseling

Housing Counseling Intake Form

Part One: Biographic and Demographic Info

Part Two: Employment Status Info

Part Three: Housing Status and Housing Goals

Part Four: Rental or Mortgage Info

If you own your property answer the following Section.

Part Five: Credit, Income, Debt and Monthly Expenses

Debt