DATA INTAKE FORM. Address: Fax: Send authorization via: LOAN INFORMATION

2

_{Mortgage payment: $}

₂

_{Mortgage Interest Rate:}

_%

_{Don’t Know}

_□

Status of Loan: Current

_□

30-60 days

_□

61-90 days

_{□ 91-120 days □}

121-180 days

_{□ 181+ days □}

DATA INTAKE FORM

Date:

Call In

_{□ or Walk In □ CMAX #:}

Start Time:

End Time:

Borrower:

Co-Borrower:

DOB:

Age:

DOB:

Age:

Gender: M

□ F□

Race

Hispanic: Y

□ N □ Gender: M □ F□ Race

____

Hispanic: Y

□ N □

Education level: _______Military Status:________

Education: _____________ Military Status: ______________

Property Address: City:______________ Zip Code:__________County: ________________

Mailing Address

Home Phone#

Best time to contact you?

Cell Phone#

Work#

Email Address:

Fax:

Send authorization via:

How did you hear about us?

Household Information:

Family Size

Single

□

Single parent female-head

□

Single parent male-head

□

Married with children

□

Married without children

□

Two or more unrelated adults

□

Other

□

Total Household Income: $

Part-time income

□ $

Source(s) of Income:

Salary

_{□ $}

Pension

_{□ $}

SSI

_{□ $}

Unemployment

_{□ $}

_

Food Stamps

_{□ $ Alimony□$}

SSDI

_{□ $}

TANF

_{□ $}

Child Support

□ $

Lender:

LOAN INFORMATION

Contact Number:

Have you been in contact with your lender?

_{Y□ N□}

Last Date of Contact?

Status of Loan: Current

_□

30-60 days

_□

61-90 days

_{□ 91-120 days □}

121-180 days

_{□ 181+ days □}

Current Interest Rate?

_% Don’t know

_□

Current Payment? $

Don’t Know

_□

Purchase Date:

Purchase Price: $

Principal Balance Owed? $

Type of Loan: Conventional

_{□ Interest Only □ VA/FHA □ ARM □}

Have you refinanced?

_{Y□ N□}

Date of Last Refinance:

2

_Mortgage?

_Y

_{□ N□}

_Lender:

Property Value: $

Contact#

What brought you to Southside Community Development & Housing Corporation?

Late Payments

_□

Refinance

_□

Loan Reset

_{□ Reset Date:}

Loan Modification

_□

Other

_{□ Explain}

Delinquent Loans:

Initial cause of default:

How many months are you behind?

SOUTHSIDE COMMUNITY DEVELOPMENT & HOUSING CORPORATION AUTHORIZATION & DISCLOSURE

Office Use Only

Lender 1st Loan # 2nd Loan

Counselor Office Phone Fax

Borrower:

Date of Birth:

Social Security #:

Address:

Phone #: Day:

Eve:

Cell:

Co-Borrower:

Date of Birth:

Social Security #:

Address:

Phone #: Day:

Eve:

Cell:

D

Southside Community Development & Housing Corporation is an organization that provides homeownership counseling to homebuyers and foreclosure prevention counseling for homeowners. Southside Community Development & Housing Corporation assists clients through homeownership counseling and education services.

There are many real estate brokers, mortgage lenders and mortgage brokers and you, as a client of Southside Community Development & Housing Corporation, are free to choose whomever you please to provide these types of services to you.

A

F

P

C

I/We authorize Southside Community Development & Housing Corporation, its staff or representatives, to act on my/our behalf for the purpose of seeking a resolution with regard to the property listed above. I/We authorize our lending institution/mortgage company to fax, mail, or email any items requested by Southside Community Development & Housing Corporation in reference to our mortgage delinquency immediately. I understand that Southside Community Development & Housing 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. I understand that Southside Community Development & Housing Corporation 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. I give permission for NFMC program administrators and/or their agents to follow-up with me for the purposes of program evaluation. I acknowledge that I have received a copy of the Southside Community Development & Housing Corporation Privacy Policy.

A

A

C

Pursuant to Public Law 91-50B, Title VI, Section 604 (2) & (3) A & B and Section 610 (a) – (d), I/We hereby authorize any Credit Reporting Agency to disclose any consumer credit information to Southside Community Development & Housing Corporation and hereby name Southside Community Development & Housing Corporation as the authorized “person of my choosing”. I/We authorize them to obtain my credit report for the purpose of discussing and/or negotiating all matters regarding pre- and post-purchase counseling. Additionally, you may discuss my file with /Southside Community Development & Housing Corporation personnel (Law No. 1610 (d) 1). I understand that I may be referred to other housing services of the organization or another agency or 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. 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. I understand that Southside Community Development & Housing Corporation provides information and education on numerous loan products and housing programs and I further understand that the housing counseling I receive from Southside

Community Development & Housing Corporation in no way obligates me to choose any of these particular loan products or housing programs. I acknowledge that this document also serves as Southside Community Development & Housing Corporation's Privacy Policy.

A

I/we understand that Southside Community Development & Housing Corporation provides information and education on numerous loan products and housing programs and I further understand that the housing counseling I receive from Southside Community

Development & Housing Corporation in no way obligates me to choose any of these particular loan products or housing programs.

I/we have read and received a copy of this disclosure form.

_

BORROWER SIGNATURE CO-BORROW ER SIGNATURE

DATE DATE

Third Party Authorization Form

______________________________________ _______________________________________

Mortgage Lender/Servicer Name [Account][Loan] Number

The undersigned Borrower and Co-Borrower (if any) (individually and collectively, “Borrower” or “I”), authorize the above mortgage lender/servicer and its successors and assigns (individually and collectively, “Servicer”) and the following third parties

_________________________________ ____________________________________

[Counseling Agency] [Agency Contact Name and Phone Number]

_________________________________ ____________________________________

[State HFA Entity] [State HFA Contact Name and Phone Number]

_________________________________ ____________________________________

[Other Third Party] [Third Party Contact Name and Phone Number]

_________________________________________________________________________________

[Relationship of Other Third Party to Borrower and Co-Borrower]

(individually and collectively, “Third Party”) to obtain, share, release, discuss, and otherwise provide to and with each other public and non-public personal information contained in or related to the mortgage loan of the Borrower. This information may include (but is not limited to) the name, address, telephone number, social security number, credit score, credit report, income, government monitoring information, loss mitigation application status, account balances, program eligibility, and payment activity of the Borrower. I also understand and consent to the disclosure of my personal information and the terms of any agreements under the Making Home Affordable or Hardest Hit Fund Programs by Servicer or State HFA to the U.S. Department of the Treasury or their agents in connection with their responsibilities under the Emergency Economic Stabilization Act.

The Servicer will take reasonable steps to verify the identity of a Third Party, but has no responsibility or liability to verify the identity of such Third Party. The Servicer also has no responsibility or liability for what a Third Party does with such information.

This Third-Party Authorization is valid when signed by all borrowers and co-borrowers named on the mortgage and until the Servicer receives a written revocation signed by any borrower or co-borrower.

I UNDERSTAND AND AGREE WITH THE TERMS OF THIS THIRD-PARTY AUTHORIZATION:

Borrower Co-Borrower

__________________________ __________________________________

Printed Name Printed Name

__________________________ __________________________________

Signature Signature

__________________________ __________________________________

Date Date

SIGN

Before signing this Third Party Authorization, beware of foreclosure rescue scams!

• It is expected that a HUD-approved housing counselor, HFA representative or other

authorized third party will work directly with your lender/mortgage servicer.

• Please visit http://makinghomeaffordable.gov/counselor.html to verify you are working with a

HUD-approved housing counseling agency.

• Beware of anyone who asks you to pay a fee in exchange for a counseling service or

modification of a delinquent loan.

SIGN

SCDHC

Brenda Dorazio 804-231-4449

Privacy Policy

Southside Community Development & Housing Corporation (SCDHC) is 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. 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 Foreclosure

Mitigation Counseling Agreement. 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 that 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, 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.

2. If you choose to “opt-out”, we will not be able to answer 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

804.231.4449 ext 106 and do so.

Release of your information to third parties

O 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.

O 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).

O 3. Within the organization, we restrict access to nonpublic personal 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.

City: State: Zip Code:

A. Household Expenses

B. Borrower Monthly Income

Fixed Monthly Expenses Current Projected Household Income Gross Net

Mortgage Employment Income

2nd Mortgage Disability

Gas & Electric Rental Income

Heating Oil Unemployment

Water & Sewer Child Support/Alimony

Telephone Other

Car Payment 1

Car Payment 2

Auto Insurance

Co-Borrower Monthly Income

Life Insurance Household Income Gross Net

Medical Insurance Employment Income

Alimony/Child Support Disability

HOA/Condo Fees Rental Income

Property Taxes/Insurance Unemployment

Other/Credit Cards $0.00 Child Support/Alimony

Sub-Total Fixed Expenses $0.00 $0.00 Other

Variable Monthly Expenses Current Projected

C. Credit Card & Other Debts

Groceries Creditor Name

Minimum Payment Balance Eating Out Fuel/Gas Bus/Taxi/Parking Car Repair Toiletries/Hair Care Medical Prescriptions

Day Care Total Credit Cards

Cable TV Clothing/Laundry

D. Surplus/Deficit:

Sub-Total Variable Expenses

TOTAL MONTHLY EXPENSES Debt-to-Income Ratios (DTI):

Borrower: _____________________________ Date: ___________________

Co-Borrower: __________________________ Date: ___________________

Number of cars: Number of people in household:

v.10.1.2011

Monthly Household Budget

Address:

Loan #: Co-Borrower:

Additional notes: