Foreclosure Mitigation Counseling Intake Form

Please answer the following questions: YES NO• Are there any outstanding judgments against you?• Have you been declared bankrupt within the past 7 years?• Have you had property foreclosed upon or given title ordeed in lieu thereof in the last 7 years?• Do you intend to occupy the property as your primary residence?Foreclosure Mitigation Counseling Agreement and Disclosure1. Homeport (formerly Columbus Housing Partnership) is providing Foreclosure Mitigation counselingfor your benefit. Your counselor will provide you with a written plan and recommended budget;assistance in communicating with your loan servicer as necessary; and referrals to housing and / orcommunity agencies when appropriate.2. Homeport receives Congressional funds through the National Foreclosure Mitigation Counseling(NFMC) program, and, as such, is required to share some of your personal information with the NFMCprogram administrators or their agents for purposes of program monitoring, compliance, andevaluation.3. Homeport is a HUD certified housing counseling agency. HUD follows strict rules to protect yourconfidentiality. You will not be named in any reports. Although your responses may be looked atindividually by HUD, or contractors hired by HUD to collect and analyze data, your name will not beassociated with any analysis of the data. Only results from groups of people will be reported.4. Homeport develops multi-family rental housing and develops or rehabs single family homes for sale.While you may learn about these opportunities from the housing counseling staff, you are under noobligation to rent or purchase any of these homes.5. The information provided on this form does not constitute an application for mortgage assistance. Bysigning below you acknowledge that you have read and understand the above disclosure and that youare not an employee of Homeport or an immediate family member of an employee of Homeport.6. I acknowledge that I have received a copy of Homeport ’s privacy policy and practices.Signature of Applicant: ______________________________Signature of Co-Applicant: ___________________________Date: ________________Date: ________________4Revised by ldp August 19, 2011