Universal Intake Form
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4Universal Intake Form
Page 1
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If you are a previous client, counselor’s name:_______________________
How were you referred to us? ___________________________
Borrower Information:
Name: __________________________________________________________________________________________________
First
M.I.
Last
________________________
______________
____________
___________________________________
Social Security #
Date of Birth
Race
Ethnicity (Hispanic/non-Hispanic)
Address: _________________________________________________________________________________________________
Street
City
State
Zip
Home Phone: ________________________________
Cell Phone: ____________________________________
Employer: ___________________________________
Annual Income: Gross $ __________________________
Other Income? * Please identify source and amount. ________________________________________________________________
*Alimony, child support, or separate maintenance income need not be revealed if the Borrower or Co-Borrower does not choose to have it considered for repaying this loan.
Work Phone:_________________________________
Email Address: _______________________________________
Marital Status:
Married Separated
Unmarried (single, divorced, widowed)
# of People in Household? __________________
Co-Borrower Information:
Name: __________________________________________________________________________________________________
First
M.I.
Last
________________________
______________
____________
___________________________________
Social Security #
Date of Birth
Race
Ethnicity (Hispanic/non-Hispanic)
Address: _________________________________________________________________________________________________
Street
City
State
Zip
Home Phone: ________________________________
Cell Phone: ____________________________________
Employer: ___________________________________
Annual Income: Gross $ __________________________
Other Income? * Please identify source and amount. ______________________________________________________________
*Alimony, child support, or separate maintenance income need not be revealed if the Borrower or Co-Borrower does not choose to have it considered for repaying this loan.
Work Phone:_________________________________
Email Address: _______________________________________
Marital Status:
Married Separated
Unmarried (single, divorced, widowed)
Home Mortgage Loan Information
Do You Want to Keep Your Home? ________________
Are you currently living in the home? ______________________
Name of Original Mortgage Company: __________________________________________________________________________
Name of Current Mortgage Company: _________________________________________________________________________
Have You Contacted Your Lender/Servicer? Yes _____ No _____If Yes, Last Contact Date: ____________________________
Loan Number: ________________________ Current Value of Your Home: ____________________________________________
Type of Mortgage: ____
FHA ____
VA _______
Conv.______
ARM___
80/20 ___
30-Yr Fixed____
Other Identify: _____________________________________________________________________________________________
Monthly Mortgage Payment: __________________
Term:__________
Interest Rate:___________________
Date Last Mortgage Payment Made: ____________
Do You Have a Second Mortgage? _______________________
Have You Been Served Legal Papers? __________
If yes, with whom?_______________________________
How Many Months Past Due Are You?
____________________
Ever Had a Loan Modification / Forbearance Agreement? ________
When? _______________________________
Have You Filed Bankruptcy? _______________________________
When? _______________________________
Have You Ever Worked with Another Agency to Remedy Your Mortgage Default? ________________________________
If Yes, Agency’s Name: ______________________________________________________________________________
Counselor: _____________________________________
Payments to Agency (if any): $___________________
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Parent category: Business