Get Your Mortgage on Track Intake Form - Homeownership Center Dayton

FP Intake Form

Foreclosure Prevention Intake form.

Step 1 of 3

Applicant's Information
Applicant's Name:*
First Middle Last
Applicant's Social Security Number:
Co- Applicant's Information
Co-Applicant's Name:
First Middle Last
Co-Applicant's Social Security Number:
Current Address*
Street Address City State / Province / Region ZIP / Postal Code
Primary Phone*
Secondary Phone
Email Address*
Who Referred You to the HomeOwnership Center?*
I'm Having Difficulty With My Mortgage
Current Mortgage Status*
- Not behind on my mortgage
- Less than 3 months behind on my mortgage
- More than 3 months behind on my mortgage
- In foreclosure
- Scheduled for a Sheriff's Sale
Household Gross Income:*

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The Client recognizes that in order for the HomeOwnership Center of Greater Dayton (HOCGD) to provide its services, the referral source for the client, as well as other persons, firms, or organizations may request HOCGD to furnish certain information concerning the client’s financial condition. The client expressly authorizes HOCGD, its project partners, and the referral source to obtain and review information relevant to the client’s file and exchange information concerning the status of the client as deemed necessary. The client also authorizes HOCGD to obtain and review the client’s credit report(s) from TransUnion, Equifax, and/or Experian and to disclose financial information for the purposes of research related to the HomeOwnership Center’s mission. Project partners include but are not limited to: lenders, down payment assistance providers, realtors, title companies, home inspectors, Miami Valley Fair Housing Center, City of Dayton, City of Kettering, Montgomery County and funders such as the U.S. Dept. of HUD, and NeighborWorks® America. HOCGD agrees that all information in the client’s file will otherwise be kept confidential. The client understands that if referred to other services of the organization or other agencies as appropriate that may be able to assist with particular concerns that have been identified, there is no obligation to use any of the services offered. The client also understands that HOCGD provides loans in certain circumstances, and offers information and education on numerous products and programs. HOCGD is funded by or has contractual relationships with NeighborWorks America, local banks and credit unions, the City of Dayton, City of Kettering, Montgomery County, the U.S. Dept. of HUD and others. The client further understands that the guidance received from HOCGD in no way represents an obligation to choose any of these loan products or housing programs. The client agrees to hold HOCGD, their employees, officers and agents harmless from any claim, suit, action or demand in connection with any services rendered by HOCGD to the client. The client understands that any fee paid to HOCGD is not refundable and that HOCGD has no obligation for approval related to the loan application process, or actions to terminate foreclosure proceedings.

Check the following box if you agree agree with the terms outlined in the Waiver and Authorization to Release Information Statement.
*
- Yes-I Agree
The HomeOwnership Center of Greater Dayton is committed to assuring the privacy of individuals and/or families who have contacted us for assistance. We realize that the concerns that you bring us are highly personal in nature. We assure you that all information shared both orally and in writing will be managed within legal and ethical considerations. Your “nonpublic personal information,” such as your total debt information, income, living expenses and personal information concerning your financial circumstances, will be provided to creditors, program monitors, and others only with your authorization and signature on the Waiver and Authorization to Release Information. We may also use anonymous aggregated case file information for the purpose of evaluating our services, gathering valuable research information and designing future programs.

Types of information we gather about you • Information we receive from you orally, on applications or other forms, such as your name, address, social security number, assets and income; • Information about your transactions with us, our affiliates, 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 of certain disclosures 1. You have the opportunity to “opt-out” of disclosures of your nonpublic personal information to third parties (such as your creditors), that is, direct us not to make those disclosures (other than disclosures permitted by law). 2. If you choose to “opt out,” we will not be able to answer questions from your creditors or other third parties. If at any time, you wish to “opt out” or change your decision with regard to your “opt out,” you may do so by submitting your request in writing to: HomeOwnership Center of Greater Dayton, Privacy Policy, 130 West Second Street, Suite 1420, Dayton, OH 45402. Release of your information to third parties 1. So long as you have not opted out, we may disclose some or all of the information that we collect, as described above, to your creditors or third parties where we have determined that it would be helpful to you, would aid us in counseling you, or is a requirement of grant awards which make our services possible. 2. We may also disclose any nonpublic personal information about you or former customers to anyone as permitted by law (e.g., if we are compelled by legal process). 3. Within the organization, we restrict access to nonpublic information about you to those employees who need to know that information to provide services to you. We maintain physical, electronic and procedural safeguards that comply with federal regulations to guard your nonpublic personal information.

Click the checkbox above if you agree with the terms outlined in our Privacy Policy.
*
- Yes-I Agree
1. I understand that the HomeOwnership Center of Greater Dayton, a program of St. Mary Development Corporation, provides foreclosure mitigation counseling after which I will receive a written action plan consisting of recommendations for handling my finances, possibly including referrals to other housing agencies as appropriate. 2. I understand that the HomeOwnership Center receives Congressional funds through the National Foreclosure Mitigation Counseling (NFMC) program and, as such, is required to share some of my personal information with NFMC program administrators or their agents for purposes of program monitoring, compliance and evaluation. 3. I give permission for NFMC program administrators and/or evaluators to follow-up with me for up to three (3) years from the date of this signed form for the purposes of program evaluation. 4. I acknowledge that I have received a copy of the HomeOwnership Center’s Privacy Policy. 5. I may be referred to other services of the organization or other agencies as appropriate that may be able to assist with particular concerns that have been identified. I understand that I am not obligated to use any of the services offered to me. 6. A counselor may answer questions and provide information, but not give legal advice. If I want legal advice, I will be referred for appropriate assistance. 7. I understand that the HomeOwnership Center provides information and education on numerous loan products and housing programs. The organization is funded by or has contractual relationships with NeighborWorks America, Ohio Department of Development, Federal Home Loan Bank of Cincinnati, local banks and credit unions, the City of Dayton, the City of Kettering, the Department of Housing and Urban Development and others. I further understand that the housing counseling I receive from the HomeOwnership Center in no way obligates me to choose any of these particular loan products or housing programs.

Click the checkbox below if you agree with the terms outlined in our Foreclosure Mitigation Counseling Agreement.
*
- Yes-I Agree

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FP Intake Form

Step 1 of 3

Applicant's Information

Co- Applicant's Information

I'm Having Difficulty With My Mortgage

Applicant's Demographic Information

Co-Applicant's Demographic Information

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