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HOMEBUYERS CLASS - UNIVERSAL CLIENT INTAKE FORM/FORMULARIO UNIVERSAL DE ADMISION DE CLIENTES

  1. Frederick Community Action Agency Housing Counseling Program

  2. The Frederick Community Action Agency, a HUD-Approved Housing Counseling Agency, offers a virtual Homebuyer Education Workshop. Due to COVID-19 restrictions, the workshop will be held VIA ZOOM in two 2 ½ hour sessions from 6:30 PM to 9:00 PM on Tuesday and Thursday evenings. Participants will be required to attend both sessions to earn a certificate. The certificate is required for most down-payment assistance programs but is also great for anyone considering the purchase of their first home.

    Schedule of Homebuyer Education Workshops from June, 2020 through December, 2020:

  3. Workshops will be held on the following dates:

    Tuesday March 23, 2021 and Thursday March 25, 2021
    Tuesday April 20, 2021 and Thursday April 22, 2021
    Tuesday May 18, 2021 and Thursday May 20, 2021
    Tuesday June 22, 2021 and Thursday June 24, 2021

  4. Class size is limited to 40 participants. To register for the next available class, please complete the registration form by clicking on the link below. A completed registration form is required for each person attending the class. Workshops are free and open to the public. If you have questions, please contact Pat McMorrow, Certified Housing Counselor at 301-600-6206.

  5. 1. Name – List your first, middle, and last name, and suffix (legal names only)
    Nombre – Escriba su Primer nombre, Segundo nombre, apellido y sufijo (nombres legales solamente)

  6. 2. Other names used to receive services previously? / Otros nombres que ha usado para recibir servicios anteriormente?

  7. (xxx-xx-xxxx)

  8. Citizenship Status/Estado de Ciudadanía:*

  9. 5. Current Address: / Direccion Actual:

  10. Home Occupancy Status/ Estado de ocupación de la vivienda*

  11. 6. Phone Numbers and Email / Numero de Telefono Correo electronico

  12. 7. Race – Check all boxes that apply / Raza – Marque uno de los siguientes:*

  13. 8. Ethnicity – Check only one (1) / Origen Etnico – Marque uno de los siguientes (1):*

  14. 9. Gender – Check only one (1) / Sexo – Marque uno de los siguientes (1):*

  15. Marital Status/Estado civil*

  16. 10. Family Type/Tipo de Familia – Check only one (1)/ Marque uno de los siguientes (1):*

  17. 11. Family Size – Number in Family / Miembros de la Familia – Familia Inmediata:*

  18. 12. Veteran Status – Have you been on Active Duty in the U.S. Armed Forces? – Check only one (1)
    Veterano de Guerra – Ha prestado servicio militar en las Fuerzas Armadas de los Estados Unidos – Marque uno de los siguientes (1):*

  19. 13. Disabling Condition – Do you have a Disability or Disabling Condition? – Check only one (1):
    Condición Inválida – ¿Tiene usted una deseabilidad? Marque uno de los siguientes*

  20. 14. Source and Amount of Income – How much did you earn from any of the following sources in the last 30 days
    Fuente y Cantidad de Ingreso – Cuanto dinero gano de las siguientes Fuentes en los ultimos 30 dias?: ($)

  21. ← ← How much did you earn last MONTH ?
    ← ← ¿Cuánto dinero gano el último MES ?

  22. 15. What is the highest level of school completed? – Check only one (1):
    ¿Cual fue el utimo nivel de escuela completado? Marque uno de los siguientes.*

  23. 16. Health Insurance – check or circle all health care benefits that you have:
    Seguro Médico – Marque todos los beneficios de asistencia medica que usted tiene:*

  24. 17. Who could we contact in the event of an emergency / A quien podemos contactar en caso de Emergencia:

  25. 18. Family Members – Please list all family members that currently live with you:
    MIEMBROS DE LA FAMILIA – Por favor escriba todos los miembros de su familia que actualmente viven con usted:

  26. Name – First/MiddleInitial/Last
    Nombre: Primero/Segundo/Apellido

  27. Date of Birth (if known)
    Fecha de Nacimiento (si sabe)

  28. Social Security Number (if known)
    Número de Seguro Social (si sabe)

  29. Relationship/ Relacion

  30. 1.

  31. 2.

  32. 3.

  33. 4.

  34. 5.

  35. 6.

  36. 7.

  37. 8.

  38. 9.

  39. 10.

  40. Referral Source/Fuente de referencia*

  41. CLIENT CONFLICT OF INTEREST DISCLOSURE STATEMENT

    The Frederick Community Action Agency is a HUD-Approved Housing Counseling Agency that provides pre-purchase homebuyer education, delinquency/default counseling, rental counseling, reverse mortgage counseling, and shelter/services for the homeless. From time to time, the Frederick Community Action Agency makes clients aware of products and/or services that we believe offer good value. These products and/or services might be available directly from the Frederick Community Action Agency, from lenders, developers, or other agencies with which Frederick Community Action Agency has a working relationship. You are under no obligation to use the products and/or services identified by the Frederick Community Action Agency, whether from us or from industry partners. Please understand that you are free to choose any lender, lending/financing product or property, from any entity, regardless of the recommendations made by the Frederick Community Action Agency Housing Counselor, and still participate in our Housing Counseling program. It is your right and responsibility to decide whether to engage in any course of Housing Counseling with the Frederick Community Action Agency, and to determine whether the counseling is suitable for you. The individualized Action Plan and direction of our counseling sessions will be based on the Action Plan that we develop together. This means to accomplish the outcomes and goals of your plan will evolve mutually between us and should be reviewed regularly during our counseling sessions. Additionally, you are under no obligation to obtain a mortgage or purchase a home and have the option to terminate the counseling program at any time for any reason.

    I have reviewed the above and accept and agree to the above stated Conflict of Interest and Disclosure Policy. Every client is required to sign this statement, indicating they have read and understand its contents.

  42. I, (Enter Name Above), certify that I have read and understand the above statement. Any questions I may have had were previously discussed with my Housing Counselor and answered to my satisfaction. I have been provided with a copy of this disclosure statement.

  43. *You are signing this statement agreement electronically. By signing above, you agree your electronic signature is the legal equivalent of your manual signature on this agreement.

  44. PRIVACY POLICY

  45. The Frederick community Action Agency 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 program monitors and others only with your authorization. We may also use anonymous aggregated case file information for the purpose of evaluating our services, gathering valuable research information and designing future programs.

  46. 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, debts, and income.

  47. Release of your information to third parties
    1. We may disclose some or all of the information that we collect, as described above, to third parties where it is required by HUD (e.g., Benefits Check-up), 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 customers to anyone as permitted by law (e.g., if we are compelled by legal process).
    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.

  48. I, (Enter Name Above), certify that I have read and understand the above statement. Any questions I may have had were previously discussed with my Housing Counselor and answered to my satisfaction. I have been provided with a copy of this disclosure statement.

  49. Leave This Blank:

  50. This field is not part of the form submission.