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HOMEOWNERSHIP EDUCATION INTAKE FORM/FORMULARIO DE ADMISIÓN DE EDUCACIÓN DE PROPIEDAD DE VIVIENDA

  1. City of Frederick Department of Housing and Human Services
  2. The City of Frederick Department of Housing and Human Services, a HUD-Approved Housing Counseling Agency, offers a virtual Homebuyer Education Workshop. The workshop is held VIA ZOOM in three-hour sessions from 6:30 PM to 9:30 PM on Tuesday and Thursday evenings. Participants are required to attend both sessions to earn a certificate. The certificate is required for most down-payment assistance programs but is also great for anyone considering the purchase of their first home.

    Schedule of Homebuyer Education Workshops from January 2022 through June 2022:
  3. Workshops will be held on the following dates; Please check the date you wish to attend:*
  4. *Please note: Registration closes Thursday at 3:00 PM the week prior to the class
  5. Class size is limited to 40 participants. To register for an available class, please complete the registration form by clicking on the link below. A separate, completed registration form is required for each person attending the class. Workshops are free and open to the public. If you have questions, please contact Steve Rose, Certified Housing and HECM Counselor at 301-600-2077 or Pat McMorrow, Certified Housing and HECM Counselor at 301-600-6206.
  6. 1. Name – List your first, middle, and last name, and suffix (legal names only)
    Nombre – Escriba su Primer nombre, Segundo nombre, apellido y sufijo (nombres legales solamente)
  7. 2. Other names used to receive services previously? / Otros nombres que ha usado para recibir servicios anteriormente?
  8. (xxxx)

  9. (Month/Day/Year)

  10. 5. Current Address: / Direccion Actual:
  11. 6. Phone Numbers and Email / Numero de Telefono Correo electronico
  12. 7. Military Status – Have you served in the U.S. Military? – Check only one (1) box:
    Estado militar: ¿ha prestado servicio en las Fuerzas Armadas de los EE. UU.? – Marque uno de los siguientes (1):*
  13. 8. Race – Check all boxes that apply / Raza – Marque uno de los siguientes:*
  14. 9. Ethnicity – Check only one (1) / Origen Etnico – Marque uno de los siguientes (1):*
  15. 10. Gender – Check only one (1) / Sexo – Marque uno de los siguientes (1):*
  16. 11. Preferred Language:/ Idioma preferido:*
  17. 12. Citizenship Status/Estado de Ciudadanía:*
  18. 13. What is your Marital Status/Cuál es tu estado civil*
  19. 14. Family Type/Tipo de Familia – Check only one (1)/ Marque uno de los siguientes (1):*
  20. 15. Family Size – Number in Family / Miembros de la Familia – Familia Inmediata:*
  21. 16. Current Living Situation/Housing Status / Situación de vida actual/Estado de vivienda:*

  22. Housing Notes:
  23. 17. Type of Most Recent Residence – Where did you stay last night? /Tipo de residencia más reciente: ¿dónde se quedó anoche?*
  24. * Veteran’s Administration Supportive Housing (VASH) ** Grant and Per Diem (GPD) Transition in Place (TIP) Program
  25. 18. Length of Stay at Most Recent Residence (see above)/Duración de la estadía en la residencia más reciente (ver arriba)*
  26. 19. Relationship to Head of Household/Relación con el jefe de hogar*
  27. 20. Have you been diagnosed with a disability or disabling condition that impacts your life/work? / ¿Ha sido diagnosticado con una discapacidad o condición incapacitante que afecta su vida/trabajo?*
  28. If yes, please explain/En caso afirmativo, explíquelo porfavor

  29. 21. Work Status (18 & older only), Check only one (1) box:/Estado laboral (18 años y mayores únicamente), marque solo una (1) casilla:*
  30. 22. What is the highest level of school completed? – Check only one (1):
    ¿Cual fue el utimo nivel de escuela completado? Marque uno de los siguientes.*
  31. 23. Referral Source/Fuente de referencia*
  32. 24. Who could we contact in the event of an emergency:/A quién podemos contactar en caso de una emergencia:
  33. 25. Source and Amount of Income – How much do you earn/receive from any of the following sources:/Fuente y cantidad de ingresos: cuánto gana/recibe de cualquiera de las siguientes fuentes:
  34. ← ← How much did you earn last MONTH ?
    ← ← ¿Cuánto dinero gano el último MES ?
  35. 26. Non-Cash Benefits – Do you receive any of these? – How much?/Beneficios no monetarios: ¿recibe alguno de estos? - ¿Cuánto?
  36. $

  37. Don’t receive Non-Cash Benefits/ No reciba beneficios que no sean en efectivo
  38. Acknowledgements and Consent to Participate in Servicepoint and U.S. Department of Housing & Urban Development Records
  39. Acknowledgements: The information that I have provided is true and accurate to the best of my knowledge. Furthermore, I understand that rules for acceptance into programs are the same for everyone without regard to race, color, national origin, age, sex or handicap. I also understand that I have the right to appeal a decision if I feel services have been incorrectly denied, reduced, suspended, or terminated.
  40. By signing this consent form, you authorize this agency:
    • To share your intake information with the City of Frederick, Department of Housing and Human Services.
    • To share your basic demographic information, residential, employment skills/income, military/legal, service needs, goals and outcomes, medical history, substance abuse and mental health history with collaborating agencies.
    • To allow your information to be shared electronically via a secure, encrypted, web-based system with U.S. Department of Housing & Urban Development.
    • To allow your records and information to be shared for a period of no greater than ten (10) years from today’s date.
  41. Enter Client/Participant Name

  42. Check One box*
  43. I understand that collaborating agencies are fully bound by the provisions of the Health Insurance Portability and Accountability Act (HIPAA), federal regulations governing Confidentiality and Drug Abuse Patient Records (42 CFR part 2), and the Maryland Confidentiality of Medical Records Act (MCMRA) when sharing information. I understand that I may ask to have this information removed from the computerized record keeping system at any time in the future.
  44. Electronic Signature

  45. *You are signing this statement agreement electronically. By signing above, you agree your electronic signature is the legal equivalent of your manual signature on this agreement.
  46. CLIENT CONFLICT OF INTEREST DISCLOSURE STATEMENT
  47. The City of Frederick Department of Housing and Human Services is a HUD-Approved Housing Counseling Agency that provides pre-purchase homebuyer education, delinquency/default counseling, rental counseling, reverse mortgage counseling, and shelter/services for the homeless. From time to time, the City of Frederick Department of Housing and Human Services makes clients aware of products and/or services that we believe offer good value. These products and/or services might be available directly from the The City of Frederick Department of Housing and Human Services, from lenders, developers, or other agencies with which the City of Frederick Department of Housing and Human Services has a working relationship. You are under no obligation to use the products and/or services identified by the City of Frederick Department of Housing and Human Services, whether from us or from industry partners. Please understand that you are free to choose any lender, lending/financing product or property, from any entity, regardless of the recommendations made by the City of Frederick Department of Housing and Human Services Housing Counselor, and still participate in our Housing Counseling program. It is your right and responsibility to decide whether to engage in any course of Housing Counseling with the City of Frederick Department of Housing and Human Services, and to determine whether the counseling is suitable for you. Any individualized Action Plan and direction of our counseling sessions will be based on the Action Plan that we develop together. This means that accomplishing the outcomes and goals of your plan will evolve mutually between us and should be reviewed regularly during our counseling sessions. Additionally, 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 for any reason.
  48. I have reviewed the above and accept and agree to the above stated Conflict of Interest and Disclosure Policy. Every client is required to sign this statement, indicating they have read and understand its contents.
  49. I, (Enter Name Above), certify that I have read and understand the above statement. Any questions I may have had were previously discussed with my Housing Counselor and answered to my satisfaction. I have been provided with a copy of this disclosure statement.
  50. *You are signing this statement agreement electronically. By signing above, you agree your electronic signature is the legal equivalent of your manual signature on this agreement.
  51. PRIVACY POLICY
  52. The City of Frederick Department of Housing and Human Services is committed to assuring the privacy of individuals and/or families who have contacted us for assistance. We realize that the concerns you bring to us are highly personal in nature. We assure you that all information shared both orally and in writing will be managed within legal and ethical considerations. Your “nonpublic personal information” such as your total debt information, income, living expenses and personal information concerning your financial circumstances, will be provided to program monitors and others only with your authorization. We may also use anonymous aggregated case file information for the purpose of evaluating our services, gathering valuable research information, and designing future programs.
  53. Types of information that we gather about you:
    • Information we receive from you orally, on applications or other forms, such as your name, address, last 4 digits of your social security number, assets, debts, and income.
  54. Release of your information to third parties
    1. We may disclose some or all of the information that we collect, as described above, to third parties where it is required by HUD (e.g., Benefits Check-up), or is a requirement of grant awards which make our services possible.
    2. We may also disclose any nonpublic personal information about you or former customers to anyone as permitted by law (e.g., if we are compelled by legal process).
    3. Within the organization, we restrict access to nonpublic personal information about you to those employees who need to know that information to provide services to you. We maintain physical, electronic and procedural safeguards that comply with federal regulations to guard your nonpublic personal information.
  55. I, (Enter Name Above), certify that I have read and understand the above statement. Any questions I may have had were previously discussed with my Housing Counselor and answered to my satisfaction. I have been provided with a copy of this disclosure statement.
  56. *You are signing this statement agreement electronically. By signing above, you agree your electronic signature is the legal equivalent of your manual signature on this agreement.
  57. Leave This Blank:

  58. This field is not part of the form submission.