HomeStart Intake Form

PLEASE FILL OUT THE FOLLOWING FORM AND OUR INTAKE SPECIALISTS WILL FOLLOW UP AS SOON AS POSSIBLE

Basic information

First Name

Last Name

Phone

Address Line 1

Address Line 2

City

State

Zip code

Date of birth - Month

Date of birth - Day

Date of birth - Year

Marital status

Comments (if necessary)

Is your household English proficient?

Comments (if necessary)

Do you need any accommodations?

Comments (if necessary)

How do you prefer to be contacted?

Comments (if necessary)

How did you hear about CDCU?

Comments (if necessary)

Household information

The following information will help us to understand your background, household make-up and potential program

eligibility. It will in no way positively or negatively impact or influence the assistance we provide.

Total # of people in household

Total # of people over 18 in household

Household status

Comments (if necessary)

Household type

Comments (if necessary)

Do any of the following apply to anyone in your household? (select all that apply)

Certified teacher

Sworn law-enforcement officer

Firefighter or certified emergency medical technician

What is your household's primary ethnicity?

Comments (if necessary)

What is your household's primary language?

Comments (if necessary)

What is your household's highest level of education?

Comments (if necessary)

Is there a co-client/co-applicant/co-borrower?

Comments (if necessary)

Have you owned a house in the last 3 years?

Comments (if necessary)

Are you currently working with a relator?

Comments (if necessary)

Are you currently working with a lender?

Comments (if necessary)

Financial information

This basic information will help us get an initial picture of your current financial circumstances – we may seek additional information following the intake process so that we can better assist you with your goals.

Do you have a stable income?

Are you behind on your mortgage/rent/other payments?

If you have experienced financial hardship, could it be in any way attributable to the Covid 19 pandemic?

Current / latest known credit score

Approx. gross annual household income ($)

Approx. monthly rent,/mortgage + utilities ($)

Approx. other monthly household expenses ($)

Approx. mortgage balance outstanding, if applies ($)

Approx. total debt excluding mortgage ($)

What is your employment status?

What is the primary employment status of other household adult(s)?

Additional information

Please provide any other comments on your housing goals

Contact Information

Disabled	Veteran	Disabled Veteran
Active military duty	Elderly (65+)	Born outside US

HomeSt﻿﻿﻿﻿art Intake Form

HomeStart Intake Form