Housing Counseling Program Intake Form

Please complete the following intake form and be ready to provide copies of the following documents:

Driver License or State ID
Paystubs (most recent and consecutive for the last 30 days)
Bank Statements (all pages, most recent and for the past 2 months)
Tax Returns for the past 2 years (including all W2s and all schedules)
Utility Bills: Gas, Electricity, Water, Phone/Cable and Credit Card Bills
Profit & Loss Statement if self-employed (min. 3 months with accompanying bank statements)
Other Income (if applicable): Unemployment, Child Support, Social Security/Disability Benefits
Pre-approval Letter from Lender (if applicable)
Credit Report Fee $34.00/person (Pre-Purchase Counseling Only)

First Name

Middle Name

Last Name

Address

Street Address

Street Address Line 2

City

State

Zip Code

County

Home Phone

Work Phone

Cell Phone

Date of Birth

Gender

Race

Ethnicity-Hispanic?

Marital Status

Housing

# of People Living in the Home

Total Gross (Before Taxes) Family Income

Estimate of Debt Expenses (Monthly)

Monthly Income

Enter the monthly income amount for each income source checked above

Family Type

Education (Highest Level Completed)

How Did You Hear About Us?

Single Parent Dreams Can Come True!