Reverse Mortgage Intake Form Reverse Mortgage Intake form. Step 1 of 3 33% Applicant's Information Applicant's Name:* First Middle Last Applicant's Gross Income:* Co- Applicant's Information Co-Applicant's Name: First Middle Last Co-Applicant's Gross Income: Address and Contact Information Current Address* Street Address City State / Province / Region ZIP / Postal Code Primary Phone*Secondary PhoneEmail Address* Who Referred You to the HomeOwnership Center?* I'd Like to Explore a Reverse MortgageCurrent Approximate Value of your Home:* Amount You Currently Owe on Your Mortgage:* Why are you seeking a reverse mortgage?*Tell us the main reason you are thinking about a reverse mortgage. Pay off debt (mortgage, credit card, personal loan, other debts) Pay for health or disability-related expenses Pay for home repairs or improvements Extra income for everyday expenses (other than health needs) Improve quality of life or to afford extras Plan ahead for emergencies or unexpected expenses Provide financial help to family HECM for home purchase HECM refinance How much money do you need from a reverse mortgage?*For the amount you just entered, is that a lump sum or a monthly amount?* Lump sum Monthly Applicant's Demographic InformationApplicant's Race:*American Indian/Alaskan NativeAsianBlack or African AmericanNative Hawaiian/Other Pacific IslanderWhiteAmerican Indian or Alaskan Native and WhiteAsian and WhiteBlack or African American and WhiteAmerican Indian or Alaskan Native and Black or African AmericanOtherI do not wish to furnish this informationApplicant's Race (Other)If the applicant's race was not shown in the options above, please indicate the applicant's race here. Applicant's Ethnicity:* Hispanic Non-Hispanic Number in Applicant's Household:* Applicant's Gender:* Male Female Applicant's Birth Date:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does the Applicant Have a Disability or Special Needs?* Yes No Applicant's Marital Status:* Single Married Applicant's Education:* College Grad School High School/GED Vocational School Junior High School Primary School Is the Applicant Foreign Born? Yes No Is the Applicant a Veteran? Yes No Co-Applicant's Demographic InformationCo-Applicant's Race:American Indian/Alaskan NativeAsianBlack or African AmericanNative Hawaiian/Other Pacific IslanderWhiteAmerican Indian or Alaskan Native and WhiteAsian and WhiteBlack or African American and WhiteAmerican Indian or Alaskan Native and Black or African AmericanOtherI do not wish to furnish this informationCo-Applicant's Race (Other)If the applicant's race was not shown int he options above, please indicate the applicant's race here. Co-Applicant's Gender: Male Female Co-Applicant's Birth Date:Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does the Co-Applicant Have a Disability or Special Needs? Yes No Co-Applicant's Education: College Grad School High School/GED Vocational School Is the Co-Applicant Foreign Born? Yes No Is the Co-Applicant a Veteran? Yes No 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
