Online Intake Form

State


Highest level of education: GEDHigh SchoolAssociate's DegreeBachelor's DegreeMaster's DegreeDoctor's Degree

Gender MaleFemaleOtherPrefer Not to Answer

Ethnicity HispanicNot Hispanic

Race African AmericanAmerican Indian/Alaska NativeAsianCaucasianNative Hawaiian or Pacific Islander

Marital Status MarriedSingle

Handicapped Status YesNo

Military Veteran YesNo

Children Under 18? YesNo


Current Housing Information

Choose one of the following: Renter (market rent)Renter (public housing)Renter (Section 8)Renter (subsidized)Living with family/friendsOther

Are you a ...
... first-time homebuyer? YesNo
... first-generation homebuyer? YesNo


Participant's Personal Information

There are currently people residing in my home.


Participant's Income Information

First Employer: Phone Number:
Gross Income (before taxes): $ per HourWeekMonthBi-Monthly

Second Employer: Phone Number:
Gross Income (before taxes): $ per HourWeekMonthBi-Monthly

Other Income:

(Fill out any that apply)

Child Support: $
Unemployment: $
Veteran's Benefits: $
Alimony: $
Social Security: $
Worker's Compensation: $
Disability: $
TANF: $


Co-Participant's Income Information

(Note: Skip this section if only one person is participating.)

State


Highest level of education: GEDHigh SchoolAssociate's DegreeBachelor's DegreeMaster's DegreeDoctor's Degree

Gender MaleFemaleOtherPrefer Not to Answer

Ethnicity HispanicNot Hispanic

Race African AmericanAmerican Indian/Alaska NativeAsianCaucasianNative Hawaiian or Pacific Islander

Marital Status MarriedSingle

Handicapped Status YesNo

Military Veteran YesNo

Children Under 18? YesNo

First Employer: Phone Number:
Gross Income (before taxes): $ per HourWeekMonthBi-Monthly

Second Employer: Phone Number:
Gross Income (before taxes): $ per HourWeekMonthBi-Monthly

Co-Participant's Other Income:

(Fill out any that apply)

Child Support: $
Unemployment: $
Veteran's Benefits: $
Alimony: $
Social Security: $
Worker's Compensation: $
Disability: $
TANF: $


Household Expenses

Please list the average monthly expenses in your household.
Rent: $ Car Payment: $ Personal Loans: $
Mortgage: $ Credit Cards (All): $ Medical Bills: $
Electric Bill: $ Child Support: $ Cable/Internet: $
Gas Bill: $ Alimony: Car Insurance: $
Water & Sewer Bill: $ Phone Bill: $
Other 1 - Type of Bill: Amount $
Other 2 - Type of Bill: Amount $

I/we have $ available for down-payment, closing costs and reserves.

I/we can save an additional $ per month for my expenses.


Disclosure Statement

Mon Valley Initiative (MVI) is providing Homebuyer Education and/or Home Ownership Counseling for your benefit, and in this capacity its primary responsibility is to you. MVI also develops or rehabs and sells single family homes, and as such its primary responsibility is to itself. This creates a dual agency relationship between you and MVI. By submitting this form, you consent to MVI's operating in a dual agency capacity and acknowledge that as a seller, MVI may be acting in its own best interests relative to the sale of its homes. If you wish, you may retain the services of a real estate agent or a counselor who will represent only your interest in the transaction.

From time to time, the Mon Valley Initiative makes our clients aware of products and/or services that we believe offer good value to our clients. These products and/or services might be available directly from the Mon Valley Initiative, from lenders, developers, or other agencies with which we have a working relationship, including but not limited to finance partners such as the United States Department of Housing and Urban Development and the Pennsylvania Housing Finance Agency. You are under no obligation to use the products and/or services identified by the Mon Valley Initiative or from industry partners. Please understand that you are free to choose any lender, lending/financing product, or home, from any entity regardless of the recommendations made by the Mon Valley Initiative representative and still participate in our counseling program.

It is your right and responsibility to decide whether to engage in any course of counseling with the Mon Valley Initiative 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 case management plan that we will develop together. The means to accomplish the outcomes and goals of your plan will evolve mutually between us and should be reviewed regularly during our counseling sessions. 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 and for any reason. In addition to housing counseling, the Mon Valley Initiative also provides services through a workforce and business development program and a real estate development program whereby we build new homes and rehabilitate homes. Also, the Mon Valley Initiative owns rental units, and assists in revitalizing shopping and business districts throughout the Mon Valley.

While you may learn about homeownership opportunities from the housing counseling staff, you are under no obligation to purchase any of these homes as a condition of receiving counseling services from MVI.

Furthermore, the information provided on this form does not constitute an application for mortgage financing, mortgage insurance, or for down payment assistance programs. Housing counselors will offer objective advice, if requested, about loan products for which your household may be eligible. Your household is free to select lenders and lending products of your own choosing.

By submitting this form, you acknowledge that you have read and understand the above disclosures.


Typed Electronic Signatures

Please read the disclosure statement, then type your name, and today's date.

Participant's Name: Today's Date:

Co-Participant's Name (if any):