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Client Intake

Client Intake Form

  • Part I: HOMEOWNER/CLIENT INFORMATION

  • Please enter phone number in "999-999-9999" format.
  • Please enter phone number in "999-999-9999" format.
  • Part II: DEMOGRAPHICS

  • Enter Birth Data in MM/DD/YYYY format.
  • If you live alone your family size is "1"
  • If no dependents input "0"
  • Enter number of years of job duration. If 0 years, please enter 0.
  • Part III: HOUSEHOLD INCOME

  • For households and individuals, gross income is the sum of all wages, salaries, profits, interest payments, rents, and other forms of earnings, before any deductions or taxes.
  • The amount an individual earns after subtracting taxes and other deductions from gross income.
  • (Job, SSI, Unemployment, VA)
  • Total Gross Amount Earned Monthly
  • For households and individuals, gross income is the sum of all wages, salaries, profits, interest payments, rents, and other forms of earnings, before any deductions or taxes.
  • The amount an individual earns after subtracting taxes and other deductions from gross income.
  • (Job, SSI, Unemployment, VA)
  • Part IV: HOUSEHOLD ASSETS

  • Institution Type
  • Institution Type
  • Sum of Borrower and Co-Borrower Cash/Market Value
  • Part V: MONTHLY HOUSEHOLD EXPENSES

  • Single Family Home, Multi Family Home, Condominium, Townhouse, Apartment, Mobile Home, etc.
  • For example, a multifamily home can have 2-4 units
  • Part VI: MORTGAGE INFORMATION (if applicable)

  • Name of lender
  • Part VII: HOME OWNERSHIP/MORTGAGE ISSUES

  • Family Monthly Budget

  • Please fill out the Family Monthly Budget. This monthly budget will be used during your counseling session with our certified Housing and Urban Development (HUD) Housing Counselor



    To Family Monthly Budget



  • Counseling Agreement & Privacy Policy

  • COUNSELING AGREEMENT

    Dear Client:

    Upon completion of your counseling session with your counselor, you are given an Action Plan to aid you in the expectations from USA Homeownership Foundation, Inc.. Please understand that there is a high volume of clients who are in similar situations and we are trying our best to meet their needs as our capacity will allow.


    I UNDERSTAND THAT:
    1. USA Homeowership Foundation, Inc.’s workshop provides counseling advice through its counselors, educators, and its Partners/Supporters. Its is your sole responsibility to seek any future services that may be needed. This file and supporting document will be retained by VAREP and information provided might be shard with USA Homeownership Foundation Inc., partners, supporters or 3rd parties to provide service to you.

    2. USA Homeownership Foundation Inc., may receiver funding from the US Dept of HUD and/or HUD Intermediaries and as such, is required to a) share some of my personal information with HUD program administrators or their agents; b) to open my file to be reviewed for purposes of program monitoring, compliance, c) to conduct follow up with me related to program evaluation.

    3. USA Homeownership Foundation Inc., and its nonprofit partners provide housing counseling after which I will receive a written action plan consisting of recommendation for handling my finances, credit, and possibly including referrals to housing agencies as appropriate.

    4. A counselor may answer and provide information, but not give legal advice. If I want legal advice, I will be referred for appropriate assistance.

    5. USA Homeownership Foundation Inc., and its nonprofit partners provide information and education on numerous loan products and housing programs and I further understand that the housing counseling I receive from USA Homeownership Foundation Inc., in no way obligates me to choose any of these particular products or housing programs.

    6. I may be referred to other housing services of the organization, another agency or agencies as appropriate that may be able to assist with my particular concerns that have been identified. I also understand that I am not obligated to use any of the services offered to me.

    7. USA Homeownership Foundation Inc., hosts Workshops to help me/participating individuals among other services distinguish legal problems from non-legal problems, and to refer them to service providers, agencies, organizations, or other lawyer sources to provide them with any necessary substantive legal advice or representation. I further understand that by signing and dating this form, USA Homeownership Foundation Inc., and its counselors do not and cannot provide legal advice or guidance in the course of the meetings with Participants, and do not establish or create any type of attorney-client relationships with Participants. I also understand that after consultation with counselor, Participants are urged to promptly consult with the service providers, agencies, organizations, or other lawyer referral sources to which the Participants have been referred for follow up on their potential legal issues.

    I affix my signature below in agreement of what is stated in this Counseling Agreement.
  • PRIVACY POLICY

    USA Home Ownership Foundation is a nonprofit program, a 501c3 nonprofit, and we are committed to assuring the privacy of individuals and/or families who have contacted us for assistance. We realize that the concerns you bring to us are highly personal in nature and we are committed to the responsible managements, use and protection of personal information. We assure you that all information shared both orally and in writing will be managed within legal and ethical considerations. You “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 counseling agreement. We may also use the anonymous aggregated case file information for the purpose of evaluating our services, gathering valuable research information and designing future programs.


    Types of Information Gathered

    We collect personal information to support our housing counseling program and to aid your housing counseling needs. We collect personal information about you and we may disclose the following kinds of personal information about you:

    1. I/We also understand and consent to the disclosure of public and non-public personal information by and between HomeFree-USA, the United States Department of Housing and Urban Development (“HUD”), the California Housing Finance Agency, and/or its agents or other authorized representative.

    2. Information about your transactions with us, our affiliates, your creditors. Or others, such as your account balance, payment history, parties to transactions and credit usage; and

    3. A counselor may answer and provide information, but not give legal advice. If I want legal advice, I will be referred for appropriate assistance.

    4. Information we receive from a consumer credit reporting agency, such as your credit bureau reports, your credit history and your credit worthiness.

    Types of Information Gathered

    1. You have the opportunity to “opt-out,” we will not be able to answer your questions from your creditors. If at any time, you wish to change your decision with regard to your “opt-out” you may call us at 951.444.7365 and do so.

    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 customer to anyone as permitted by law. (e.g., if we are compelled by legal process)

    Confidentiality and Security

    We restrict access to personal information about you to those of our employees, volunteers and affiliated organizations who need to know that information to provide services to you. We maintain physical and electronic procedural safeguards that comply with federal regulations to guard your nonpublic personal information. Our safeguards strive to comply with federal regulations to guard your personal information.


    Directing Us Not To Make Disclosures to Third Parties

    If you prefer that we not disclose personal information about you to unaffiliated third parties, you may opt out of those disclosures, that is, you may direct us not to make those disclosures (other than disclosures permitted by law).

    1. If you wish to opt out of disclosures to unaffiliated third parties other than nonprofit organizations involved in community development, you may check the box of the Privacy Choice Form below.

    PRIVACY CHOICE FORM

    If you want to opt out, that is direct us not to make disclosure about your personal information (other than disclosures permitted by law) as described in this notice, check the box below to indicate your privacy choice:

     

    Limit disclosure of personal information about me to unaffiliated third parties other than nonprofit organizations involved in community development, or as by law and other reporting requirements.

    Limit disclosure of personal information about me to unaffiliated third parties other than nonprofit organizations involved in community development, or as by law and other reporting requirements.
  • Date Format: MM slash DD slash YYYY
  • Counselor Agreement and Program Disclosure

  • Counselor Agreement and Program Disclosure

    (DISCLOSURE STATEMENT/USA Homeownership Foundation, Inc. COUNSELING AGREEMENT)

    Dear Customer/Client:

    On the completion of your counseling USA Homeownership Foundation, Inc. staff, you will be provided guidance and resources to assist you and respond to your expectations of your visit/call. Services can be accessed through USA Homeownership Foundation, Inc. Housing Counseling and Education Program.

    Please be advised that there is a high volume of customers who seek counseling and resources, and there might be momentary delays in services. USA Homeownership Foundation, Inc. staff will respond to your questions or request in a timely manner per counselor availability. Please review the following items regarding our services.

    We sincerely appreciate you taking the time to carefully read and understand this disclosure statement.

    I UNDERSTAND THAT:

    1. USA Homeownership Foundation, Inc., is a HUD-approved housing counseling agency and a 501(c)(3) tax-exempt nonprofit.
    2. USA Homeownership Foundation, Inc. provides and presents information, education, and resources on numerous programs which include topics in Housing, Personal Finance, Home Ownership, Lending, Debt, etc. USA Homeownership Foundation, Inc. also provides the following services.
      1. Pre-Purchase/Home-buying
      2. Post-Purchase
      3. Resolving or Preventing Mortgage Delinquency or Default
      4. Rental Assistance
      5. Homeless Services
      6. Home Improvement/Rehabilitation
      7. Personal Finance
      8. General Social Services
      9. Veteran and Servicemember Resources and Programs
    3. After receiving services I will receive a written action plan consisting of recommendation for handling my finances, possibly including referrals to other housing agencies and/or related services, as appropriate.
    4. I am under no obligation to receive, purchase, or utilize the products or services of USA Homeownership Foundation, Inc. or its partners in order to participate in the housing counseling program and/or group education workshops.
    5. A counselor may answer questions and provide information, but not give legal advice. If I want legal advice, I will be referred to a legal service provider for appropriate assistance.
    6. I may be referred to other HUD-approved housing counseling agencies, another agency or agencies as appropriate that may be able to assist with my particular concerns that have been identified. Under no circumstances am I obligated to use any of the services offered to me by USA Homeownership Foundation, Inc. and its partners/affiliates.
    7. I may be required to sign waivers and/or provide other documents including proof of identity, in order for USA Homeownership Foundation, Inc., other HUD- approved housing counseling agencies, nonprofit agencies or other agencies, to provide certain services.
    8. My information is kept confidential but may be shared with USA Homeownership Foundation, Inc.’s partner agencies that would be able to assist me; and, to USA Homeownership Foundation, Inc and/or its partners’ funders for program monitoring, reporting, compliance, and program evaluation purposes.
    9. USA Homeownership Foundation, Inc may require the use of real-time video communication, use of a computer, internet and telephone.
  • Client Disclosure

  • Client Disclosure

    USA Homeownership Foundation is pleased that you have come to us for services and we are looking forward to working with you. We are here to assist you in resolving your housing and financial issues. You are welcome to use services other than those provided by this agency and we appreciate you informing your counselor if you decide to change agencies.

    Our services may include:

    ●     The gathering essential demographic and financial information to help us resolve your housing need via intake forms and submission of documentation.

    ●     An assessment of your housing, credit and financial situation

    ●     A case management plan that provides instructions and identifies resources for resolving your housing, credit and financial needs

    ●     Individual face to face, telephone, internet, and/or group counseling designed to guide you through the process of resolving housing needs

    ●     Follow-up calls, emails, and/or letters to track the outcome of our services

    1. Pre-purhcase Counseling = Preparing for Home Purchase
    2. Pre-purchase Homebuyer Education Workshops = Online Classes
    3. Fair Housing Pre-purchase Education Workshops = Group
    4. Mortgage Delinquency and Default Resolution Counseling = Mortgage Assistance
    5. Mortgage Delinquency and Default Resolutions Workshops = Group
    6. Financial Management/Budget Counseling = Budget, Credit, Financial Counseling
    7. Financial, Budgeting and Credit Workshops = Group Education to improve Credit, Budget, and Financial Management
    8. Home Improvement and Rehabilitation Counseling = Counseling after home purchase
    9. Home Improvement and Rehabilitation Workshops = Group
    10. Rental Counseling = landlord tenant, fair housing, and eviction counseling
    11. Rental Workshops = Group
    12. Services for Homeless Counseling = Counseling and resources to assist and prevent homelessness
    13. Predatory Lending Workshops = Group education to prevent lending, real estate scams, and contractor and credit fraud
    14. Pre-purhcase Counseling = Preparing for Home Purchase

    USA Homeownership Foundation upholds the highest standards of customer service. As such, our staff members providing these services will adhere to the following guidelines:

    ●     USA Homeownership Foundation does not offer legal counsel or services. Our staff members will provide counseling, group education and instructional information only regarding your housing, personal financial management or credit situation under this program

    ●     USA Homeownership Foundation does not provide debt consolidation services nor will any member of the USA Homeownership Foundation’s staff takeover or assume responsibility for the finances of any participating client

    ●     USA Homeownership Foundation does not pay or receive fees or other considerations for referrals to our from any program administered by us

    ●     USA Homeownership Foundation staff members will not recommend that clients participate or engage in any services whereby the staff members themselves or any member of their immediate family have a financial interest

    ●     No USA Homeownership Foundation staff member will disclose any personal information without proper authorization of the participant

    ●     USA Homeownership Foundation strongly believes in and promotes housing choice and educates our clients to shop for the best person to assist them. To that end, USA Homeownership Foundation does not endorse any realtor or lender. Participants in our Pre-Purchase Counseling/Credit/VA/Down payment Assistance Programs are encouraged to shop for and select the lender and realtor that best suits their needs

    ●     USA Homeownership Foundation, in many instances, will need to pull your credit report to assess the condition of your credit either to determine your readiness for ownership or to assist in the resolution of mortgage delinquency.

    ●     Central to USA Homeownership Foundation mission is the elimination of housing discrimination and all of USA Homeownership Foundation programs and services are required to educate participants regarding fair housing laws

    ●     USA Homeownership Foundation employs persons who are qualified to provide the services rendered. To that end, all USA Homeownership Foundation employs persons who are qualified to provide the services rendered. To that end, all USA Homeownership Foundation employs persons who are qualified to provide the services rendered. To that end, all USA Homeownership Foundation housing counselors are required to be certified. New counselors employed by the USA Homeownership Foundation have one year to acquire such certification, which can be obtained through the Association of Housing Counselors, the National Federation of Housing Counselors or Neighbor Works.


    Please be advised that you, the client, are not obligated to receive, purchase or utilize any other services offered by USA Homeownership Foundation, or its exclusive partners, to receive housing counseling services. This certifies that I have read and understood the above statement of disclosure.

  • Housing Counselor: Thomas L. Griffin

Counselor Signatures

  • Date Format: MM slash DD slash YYYY