BIENESTAR HOUSING RESOURCE CENTER
A DIVISION OF COMITE DE BIEN ESTAR, INC.
963 E. “B” STREET P.O. BOX 7170, SAN LUIS, AZ 85349
PHONE: (928) 627-8559
FAX: (928) 627-9026
GENERAL INTAKE FORM
INTAKE FORM NUMBER: COUNSELOR NAME: APPLICANT INFORMATION
LAST
NAME FIRST M.I.
DOB AGE SOCIAL SECURITY NUMBER STREET ADDRESS
& P.O. BOX APARTMENT/UNIT #
CITY STATE ZIP CODE
PHONE E-MAIL ADDRESS
ARE YOU A U.S. CITIZEN? YES NO ARE YOU A PERMANENT RESIDENT OF U.S.? YES NO
WHAT IS YOUR CURRENT HOUSING
SITUATION? RENTING OWN LIVING WITH A FAMILY MEMBER LIVING IN MEXICO OTHER
ARE YOU CURRENTLY
EMPLOYED? YES NO LEVEL OF EDUCATION ATTAINED PREFERRED LANGUAGE
EDUCATION
ELEMENTARY COURSE OF STUDY
FROM
(MM/YY) TO DID YOU GRADUATE? YES NO DEGREE
HIGH SCHOOL COURSE OF STUDY
FROM
(MM/YY) TO DID YOU GRADUATE? YES NO DEGREE
COLLEGE COURSE OF STUDY
FROM
(MM/YY) TO DID YOU GRADUATE? YES NO DEGREE BUSINESS/TRADE/TECHNICAL COURSE OF STUDY FROM
RACE AND ETHNECITY RACE
ETHNICITY
WHITE BLACK OF AFRICAN DECENT ASIAN NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
ASIAN AND WHITE AMERICAN INDIAN/ALASKA NATIVE AMERICAN INDIAN OR ALASKA NATIVE AND WHITE BLACK OR AFRICAN AMERICAN AND WHITE AMERICAN INDIAN OR ALASKA NATIVE AND BLACK OR AFRICAN AMERICAN OTHER/MULTIPLE RACES I PREFER NOT TO PROVIDE THIS INFORMATION
HISPANIC NON- HISPANIC MEXICAN OTHER
HOUSEHOLD MEMBER INFORMATION
LAST NAME FIRST NAME M.I. AGE
LAST NAME FIRST NAME M.I. AGE
LAST NAME FIRST NAME M.I. AGE
LAST NAME FIRST NAME M.I. AGE
LAST NAME FIRST NAME M.I. AGE
EMPLOYMENT HISTORY
COMPANY NAME PHONE
ADDRESS SUPERVISOR NAME
JOB TITLE STARTING SALARY $ ENDING SALARY $ RESPONSIBILITIES
FRO
M TO REASON FOR LEAVING MAY WE CONTACT YOUR PREVIOUS SUPERVISOR FOR A
REFERENCE? YES NO
COMPANY NAME PHONE
ADDRESS SUPERVISOR NAME
JOB TITLE STARTING SALARY $ ENDING SALARY $ RESPONSIBILITIES
FRO
M TO REASON FOR LEAVING MAY WE CONTACT YOUR PREVIOUS SUPERVISOR FOR A
CO-APPLICANT INFORMATION
Last Name First M.I.
Date of Birth Age Social Security Number Street Address &
P.O. BOX Apartment/Unit #
City State ZIP Code
Phone E-mail Address
Are you a U.S. citizen? YES NO Are you a permanent resident of U.S.? YES NO
What is your current housing situation? Renting Own Living with a family member Living in Mexico Other Are you currently employed? YES NO Level of education attained Preferred language
EDUCATION
Elementary Course of study
From
(MM/YY) To Did you graduate? YES NO Degree
High School Course of study
From
(MM/YY) To Did you graduate? YES NO Degree
College Course of study
From
(MM/YY) To Did you graduate? YES NO Degree Business/Trade/Technical Course of Study From
(MM/YY) To Did you graduate? YES NO Degree RACE AND ETHNECITY
Race
Ethnicity
White Black of African Decent Asian Native Hawaiian or Other Pacific Islander
Asian and White American Indian/Alaska Native American Indian or Alaska Native and White Black or African American and White American Indian or Alaska Native and Black or African American Other/Multiple Races I prefer not to provide this information
Hispanic Non- Hispanic Mexican Other
HOUSEHOLD MEMBER INFORMATION
LAST NAME FIRST NAME M.I. AGE
LAST NAME FIRST NAME M.I. AGE
LAST NAME FIRST NAME M.I. AGE
LAST NAME FIRST NAME M.I. AGE
EMPLOYMENT HISTORY
COMPANY NAME PHONE
ADDRESS SUPERVISOR NAME
JOB TITLE STARTING SALARY $ ENDING SALARY $ RESPONSIBILITIES
FROM TO REASON FOR LEAVING MAY WE CONTACT YOUR PREVIOUS SUPERVISOR FOR A
REFERENCE? YES NO
COMPANY NAME PHONE
ADDRESS SUPERVISOR NAME
JOB TITLE STARTING SALARY $ ENDING SALARY $ RESPONSIBILITIES
FROM TO REASON FOR LEAVING MAY WE CONTACT YOUR PREVIOUS SUPERVISOR FOR A
REFERENCE? YES NO
SERVICES
GROUP COUNSELING DATE: NO. HOURS GROUP COUNSELING: NO OF INDIVIDUAL COUNSELING HOURS:
PROPERTY ADDRESS P.O. BOX
CITY STATE ZIP CODE
TYPE OF SERVICE:
DEBT AND MONEY MANAGEMENT COUNSELING SELF HELP PROGRAM FORECLOSURE PREVENTION ASSISTANCE PRE PURCHASE DOWN PAYMENT ASSISTANCE (AHP) DOL IDA OTHER
HAVE YOUR RECEIVED RENTAL OR UTILITY ASSISTANCE FROM ANOTHER AGENCY?
YES NO YES NO
CONFLICT OF INTEREST STATEMENT
NOTE TO APPLICANTS:
THE FOLLOWING COUNSELING SERVICES; FIRST TIME HOME BUYERS, DEBT CONSOLIDATION MANAGEMENT, COUNSELING/LOANS, FINANCIAL LITERACY CLASS, DOWN PAYMENT ASSISTANCE, FORECLOSURE PREVENTION ASSISTANCE PROGRAM/NFMC, SELF-HELP PROGRAM, MICRO BUSINESS LOANS, HOME REPAIR LOAN, VEHICLE LOAN, EDUCATION LOANS, HOME CONSTRUCTION, LAND
DEVELOPMENT, TRANSPORTATION PROGRAM AND OTHER SOCIAL AND CULTURAL PROGRAMS OFFERED BY COMITE DE BIEN ESTAR, INC. AND ITS SUBSIDIARIES, AFFILIATES OR DIRECTORS, OFFICERS, EMPLOYEES, AGENTS OR PARTNERS MAY ALSO BE OFFERED BY OTHER PROVIDERS AND YOU ARE UNDER NO OBLIGATION TO REQUEST OR UTILIZE SERVICES PROVIDED BY COMITE DE BIEN ESTAR, INC. COMITE DE BIEN ESTAR, INC. HAS FINANCIAL AFFILIATION WITH HUD, RCAC, BORDER FINANCIAL RESOURCES, NATIONAL BANK, BANK OF AMERICA, NEIGHBORWORKS AMERICA, AND THE NATIONAL COUNCIL OF LA, WHOM ARE AN INDUSTRY PARTNER.
IF ANY INFORMATION ON THIS APPLICATION IS FOUND TO BE FALSE OR INCOMPLETE, SUCH FINDING, IN ADDITION TO POSSIBLE LIABILITY UNDER CIVIL AND CRIMINAL COURT, MAY ALSO BE CONSIDERED GROUNDS FOR DENIAL OF THE REQUESTED CREDIT AND MAY BE BASIS FOR DEBARMENT FROM PARTICIPANT IN ALL FEDERAL PROGRAMS UNDER STATUTE 7 C.F.R. PART 3017
CERTIFICATION:
IF AWARDED ASSISTANCE TO PURCHASE A HOME, I (WE) WILL OCCUPY THE PROPERTY AS MY (OUR) PRINCIPAL PLACE OF RESIDENCE. SIGNATURES
I AUTHORIZE THE VERIFICATION OF THE INFORMATION PROVIDED ON THIS FORM AS TO MY PERSONAL INFORMATION REGARDING MY SELF, FAMILY, INCOME, CREDIT AND EMPLOYMENT. I HAVE RECEIVED A COPY OF THIS APPLICATION.
SIGNATURE OF APPLICANT: DATE:
