Client Intake Form Client Intake Form Step 1 of 5 20% This field is hidden when viewing the form60 DAY LETTER MM slash DD slash YYYY This field is hidden when viewing the form2ND 30 DAY LETTER MM slash DD slash YYYY This field is hidden when viewing the form1ST 30 DAY LETTER MM slash DD slash YYYY This field is hidden when viewing the formCertificate Issue Date MM slash DD slash YYYY This field is hidden when viewing the formCertificate Expiration DateThis field is hidden when viewing the formCompleted Education Full Name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last Suffix Email(Required) Enter Email Confirm Email Cell Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What service(s) are you requesting? (Select all that apply)(Required) Homebuyer Education Pre Purchase Counseling Post Purchase Counseling Financial Counseling Credit Repair Counseling Budget Counseling Foreclosure Assistance Rental Counseling Homeless Services Race(Required) American Indian/Alaskan Native Asian Hispanic Black or African American Native Hawaiian White More than one race Choose not to respond Are you Hispanic or Latino?(Required) Yes No Choose not to respond English Proficiency(Required) Yes, I am proficient in English No, I am NOT proficient in English Choose not to answer Date of Birth(Required) Month Day Year This field is hidden when viewing the formAGEGender(Required) Male Female Other/Non-Conforming How many people live in your household?(Required)12345678910 More than 10 People live in my household. Household Annual Gross Income (Estimated Before Taxes)Highest Level of Education(Required)Less than High SchoolHigh School Diploma/GEDAssociate DegreeBachelor’s DegreeMaster’s DegreeDoctorateCurrent Residence(Required)OtherOwnOwn – Empowerment ZoneOwn – Enterprise and Empowerment ZoneOwn – Enterprise ZoneRentRent – Empowerment ZoneRent – Enterprise and Empowerment ZoneRent – Enterprise ZoneDo you live in a rural area?(Required) Yes, I live in a rural area No, I do not live in a rural area I don’t know County/MSA(Required)Muscogee County- Columbus, GA-AL MSAOtherAre you a first time homebuyer?(Required) Yes No Do you have a Co-Applicant? Yes No Total Co-Apps (include spouse)12345Would you like to receive additional information from our speakers, sponsors or affiliates? Yes No Information will not be shared with any third party (e.g. credit agency of lender) without your consent.How did you hear about us? Agency Lender Mailer Realtor Word of Mouth Walk-in Are you currently employed? Yes No Are you Active Military? Yes No Are you a veteran? Yes No Employment HistoryEmployer NameJob TitleAnnual SalryLength of Employment Add RemoveIf length of employment is less than 2 years please list previous employer. Do you have a Realtor? Yes No Have you found a home? Yes No Anticipated Closing DateReal Estate Company NameRealtors NameRealtors Phone NumberRealtors Email Have you applied for a mortgage? Yes No Mortgage Company NameLoan Officers NameLoan Officers Phone NumberLoan Officers Email Co Applicant 1Co Applicant Name First Middle Last Co Applicant Address Same as previous Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Co Applicant PhoneCo Applicant Email Enter Email Confirm Email Monthly IncomeRelationship To ClientBrotherEmployerFatherFriendHusbandMotherOther RelativeSisterWifeSocial Security NumberPreferred LanguageEnglishSpanishOtherRace American Indian/Alaskan Native Asian Hispanic Black or African American Choose not to respond Native Hawaiian White More than one race Hispanic or Latino Yes No Choose not to respond Gender Male Female Other/Non-Conforming Date of Birth Month Day Year Veteran Yes No Housing Counseling Disclosures Privacy Policy Housing Counseling Disclosure(Required) I/We acknowledge that I/We received, reviewed, and agree to Urban League of the River Valley, Inc. Housing Counseling Disclosures.Privacy Policy(Required) I/We acknowledge that I/We received, reviewed, and agree to Urban League of the River Valley, Inc. Privacy Policy.Opting Out of Certain Disclosures OPT-OUT: I request that Urban League of the River Valley, Inc. make no disclosures of my nonpublic personal information to third parties other than project partners and those permitted by law. By choosing this option, I understand that Urban League of the River Valley, Inc. will NOT be able to answer any questions from my creditors. I understand that I may change my decision at any time by contacting Urban League of the River Valley, Inc. RELEASE: I hereby authorize Urban League of the River Valley, Inc. to release nonpublic personal information it obtains about me to my creditors and any third parties necessary to provide me with the services I requested. I acknowledge that I have read and understand the above privacy practices and disclosures. Applicant Signature(Required)Applicant: Upload your ID(Required)Max. file size: 100 MB.Co- Applicant Signature(Required)Co- Applicant: Upload your ID(Required)Max. file size: 100 MB.
