Foreclosure Prevention Intake Form

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Foreclosure Prevention Intake Form

Birthdate:

Employer:

Gross Income: _ Part-Time Income:

Co-Applicant’s Birthdate:

Co-Applicant’s Gross Income:

Rent  Own  Other

Persons in household: ____

# of Adults

# of Children under 18

Richmond

Henrico

Chesterfield

Hopewell

Petersburg

Male

Female

American Indian/Alaskan Native

Asian

African American or Black

Native Hawaiian or other Pacific Islander

White

American Indian & White

Asian & White

African American & White

American Indian & White

American Indian & African American

Other (specify):

Hispanic

Married

Single

Divorced Widow

Disabled

62+

Female Head of Household

Veteran Living in Rural Area: Yes  No 

Office Use:

> 100

80-100

<80

< 50

Other

The cost for our Credit Report is $20.00. If you wish to have your credit report pulled, you may pay by cash, money

order, or credit/debit card during your counseling session, or on our website under the make a “donation tab”.

AN APPLICATION FOR DPA CANNOT BE CONSIDERED UNTIL WE RECEIVED A COMPLETE APPLICATION PACKET.

PART 1 Date: _ Client Number: __

Reason for Visit:

How Did You Hear About SCDHC?

Lender

Realtor SCDHC Mail

Website Other:

Applicant:

Name:

Address:

City:

Age:

State: ________

Zip: ____________

Home #: _ Cell #: __

Email: ___________________________________

Other:

Co-Applicant:

Name:

Address:

City:

State: _ Zip: __

Home #: _ Cell #: __

Email: ___________________________________

Other:

Education:

None  High School  GED  Vocational  Other 

College: Associates  Bachelors  Masters  PhD 

Social Security #:

__________________________

Co-Applicant Social Security:

__________________________________

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SOUTHSIDE COMMUNITY DEVELOPMENT & HOUSING CORPORATION

1624 Hull Street  Richmond, VA 23224  (804) 231-4449 (Phone)  (804) 233-3020 (Fax) www.scdhc.com

SOUTHSIDE COMMUNITY DEVELOPMENT & HOUSING CORPORATION AUTHORIZATION & DISCLOSURE

D

ISCLOSURE

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

UTHORIZATION

F

ORECLOSURE

P

REVENTION

C

LIENTS

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

UTHORIZATION

A

LL

C

LIENTS

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.

P

RIVACY

S

TATEMENT

Southside Community Development & Housing Corporation 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 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. I acknowledge that this document also serves as Southside Community Development & Housing Corporation's Privacy Policy.

A

CKNOWLEDGMENT

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.

_

APPLICANT SIGNATURE CO-APPLICANT SIGNATURE

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Mortgage Loan #1

Loan Co Name:

Loan #:

FHA Case #:

Phone#:

Fax #:

Date Of Purchase:

Origination Date:

Loan Amt: $

Amt Owed(Principal Balance):$

Assessed Value: $

Interest rate:

APR:

# Of months Delinquent:

List months you are Delinquent

:

Monthly Payment Amount: $

Payment History:

Payment Plan:

Amt. to reinstate: $

Cash On Hand: $

Are you in Bankruptcy: (Yes or No)

Date Filed:

Attorney:

Foreclosure Sale Date? (Yes or No)

If yes, When?

Do you Have…

Good Faith Estimate

Truth in Lending

HUD1

Did you read all loan documents?

Y /

N

Where did the closing take place?

How long was the closing?

Were you solicited for the loan?

Y / N

Was a Broker involved?

Y /

N

Name of Broker:

Name of Broker Company:

_____________________________________________

Mortgage Loan #2

Loan Co Name:

Loan #:

FHA Case #:

Phone#:

Fax #:

Date Of Purchase:

Origination Date:

Loan Amt: $

Amt Owed(Principal Balance):$

Assessed Value: $

Interest rate:

APR:

# Of months Delinquent:

List months you are Delinquent

:

Monthly Payment Amount: $

Payment History:

Payment Plan:

Amt to reinstate: $

Cash On Hand: $

Are you in Bankruptcy: (Yes or No)

Date Filed:

Attorney:

Do you Have…

Good Faith Estimate

Truth in Lending

HUD1

Did you read all loan documents?

Y /

N

Where did the closing take place?

How long was the closing?

Were you solicited for the loan?

Y / N

Was a Broker involved?

Y / N

Name of Broker:

Name of Broker Company:

_____________________________________________

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FORECLOSURE PREVENTION SERVICES

Household's Current Financial Situation

Name:

Applicant

Income source Monthly net income

Wages/salary Benefits Food Stamps Child support Other Total $ Co-Applicant

Wages/salary Benefits Food Stamps Child support Other Total $ Other>18yrs

Wages/salary Benefits Food Stamps Child support Other Total $ Summary Total Income Total Expense Debt Payment

Deficit/Surplus $

Expense Monthly Amount

Mortgage Loan 1 Mortgage Loan 2 Mortgage Loan 3 Taxes / Insurance Electricity Gas / Oil Heat Water / Garbage Cable / Satellite Phone Cell Car Payment Car Payment Car Payment Car Insurance Gas / Fares / Parking Car Maintenance Groceries Work Lunches School Lunches Eating Out

Toiletries / Cleaning Products Dry Cleaning Laundry Hair Care Pet Care Child Support Child Care Allowances

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Guidelines to Create Hardship Letter

1. Identifying information including:

o Name

o Address

o Phone Number

o Mortgage account number

2. The first paragraph should state the workout option you are seeking. For

example, loan modification/reduction in mortgage payments.

3. Describe your hardship and reasons for it in detail.

4. Give an overview of your income and expenses and explain any anticipated

changes in income and/or expenses if any.

5. List reasons why you think the workout option you are seeking will work and

your commitment to see it through.

6. Please be sure to sign and date the letter.

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Authorization to Obtain Credit Report

I hereby authorize Southside Community Development & Housing Corporation to obtain a copy of my

credit report to assist in resolving my housing issue. A fax/copy of this authorization form is sufficient.

□

Not Applicable

Client Name:

(additional person on mortgage loan or spouse)

Social Security #:

Date of Birth:

Address:

City:

State:

Zip:

Telephone (home):

(other):

Present Employer:

Occupation:

Address:

City:

State:

Zip:

Signature:

Date:

*For office use Only**

Rev 08-13

Date Completed:

_Staff:

Score:

Client Name:

(mortgagor – primary person on mortgage loan)

Social Security #:

Date of Birth:

Address:

City:

State:

Zip:

Telephone (home):

(other):

Present Employer:

Occupation:

Address:

City:

State:

Zip:

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Southside Community Development & Housing Corporation

1624 Hull Street

Richmond, VA 23224

804-231-4449

FAX 804-233-3020

Authorization for Release of Information

I/We

and

hereby give permission to SCDHC, and specifically the following certified housing counselors, Felicia Bolling,

and Donna Stallings to provide and obtain information from the following lenders and/or persons necessary

Foreclosure Prevention Intake Form