Credit Report Request Form printable pdf download

Credit Report Request Form

Name_______________________(____)_______________________________

Last

suffix

First

Middle Initial

Social Security Number__________________Confirm_____________________

Date of Birth___________________________

Address__________________________________________________________

Number

Street Name

City

State

Zip

Mailing Address if different___________________________________________

Prev. Address if less than 6 months____________________________________

Day Phone_____________Work Phone_______________Cell______________

E-mail___________________________________________________________

I hereby authorize and instruct NORTHERN CIRCLE INDIAN HOUSING AUTHORITY

(Hereinafter referred to as NCIHA) to obtain and review my credit report. My credit report will be

obtained from a credit reporting agency chosen by NCIHA. I understand and agree that NCIHA

intends to use the credit report for the purpose of evaluating my financial readiness to purchase a

home or assist me with credit issues and may share this information with a lending institution. I

further understand that Northern Circle will run another credit check in 6 months to determine my

progress.

I understand that I may revoke my authorization by notifying NCIHA in writing.

__________________________________

______________________________________

Print name

Signature

__________________________________

Date

Optional – This information helps NCIHA identify the community we serve for HUD reporting. Your help is appreciated

RACE

GENDER

_____

** ANNUAL INCOME

Check more than one if necessary

_____Asian

_____Female

** approximate _____________

_____African-American

_____Male

FAMILY SIZE

_____Hispanic

_____Native American

_____Adults

_____Pacific Islander

_____Children

Education

_____White

_____Other

Compl Grade School____

Compl High School____

GED_______

Degree, type_____

The counseling services; financial literacy, pre and post purchase, default and delinquency, foreclosure prevention, down payment

assistance, rental assistance, homeless prevention , emergency shelter, document review that may be offered by Northern Circle Indian

Housing Authority, its subsidiaries, affiliates or directors, officers, employees, agents or partners may also be offered by other

providers and you are under no obligation to utilize any services from Northern Circle Indian Housing Authority . Northern Circle

Indian Housing Authority has financial affiliation with Bank of America, Federal Home Loan Bank, Mendo Lake Credit Union,

Resource For Native Development, Rural Communities Assistance Corporation, Savings Bank of Mendocino County, Summit

Mortgage, Umpqua Bank, United Native Housing Development Corporation, Wells Fargo Bank, who are industry partners. Rev. 1/13

Credit Report Request Form

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