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HOMEBUYERS CLASS - UNIVERSAL CLIENT INTAKE FORM/FORMULARIO UNIVERSAL DE ADMISION DE CLIENTES

3. City of Frederick Department of Housing and Human Services
5. The City of Frederick Department of Housing and Human Services, a HUD-Approved Housing Counseling Agency, offers a virtual Homebuyer Education Workshop. Due to COVID-19 restrictions, the workshop will be held VIA ZOOM in two 2 ½ hour sessions from 6:30 PM to 9:00 PM on Tuesday and Thursday evenings. Participants will be 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 June, 2020 through December, 2020:
7. Workshops will be held on the following dates:

   Tuesday, September 21 and Thursday, September 23
   Tuesday, October 12 and Thursday, October 14
   Tuesday, November 16 and Thursday, November 18
   Tuesday, December 14 and Thursday, December 16
9. Class size is limited to 40 participants. To register for the next available class, please complete the registration form by clicking on the link below. A 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 Pat McMorrow, Certified Housing Counselor at 301-600-6206.
11. 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)
13. First Name:
    Primer Nombre:*
14. Middle Name:
    Segundo Nombre:
16. Last Name:
    Apellido:*
17. Suffix:
    Sufijo:
19. 2. Other names used to receive services previously? / Otros nombres que ha usado para recibir servicios anteriormente?
21. First Name:
    Primer Nombre:
22. Middle Name:
    Segundo Nombre:
24. Last Name:
    Apellido:
25. Suffix:
    Sufijo:
27. 3. Social Security Number:
    Número de Seguro Social:
    (xxx-xx-xxxx)
28. 1. Don’t Know SS#
       No sabe # de seguro social

    1. Refused to Provide SS#
       Se niega a proveer # de seguro social
30. 4. Date of Birth
    Fecha de Nacimiento:*
31. 1. Don’t Know DOB
       No sabe fecha de nacimiento

    1. Refused DOB
       Se rehúsa a dar fecha de nacimiento
33. Citizenship Status/Estado de Ciudadanía:*

    1. Citizen

    1. Legal Resident

    1. Other
35. 5. Current Address: / Direccion Actual:
37. Street Address:
    Calle y # de apartamento:*
38. City/Town:
    Ciudad:*
40. State:
    Estado:*
41. ZIP:
    Codigo Postal:*
42. County
    Condado*
44. Home Occupancy Status/ Estado de ocupación de la vivienda*

    1. Own/propio

    1. Rent/alquilar

    1. Other/Otro
46. 6. Phone Numbers and Email / Numero de Telefono Correo electronico
48. Home/Casa:*
49. Work/Trabajo:
50. Cell/Celular:
52. Email/Correo electronico:*
54. 7. Race – Check all boxes that apply / Raza – Marque uno de los siguientes:*

    1. American Indian or Alaska Native/
       Indio Americano o Nativo de Alaska
       
    2. Asian / Asiatico
    3. Black or African American/
       Negro o Afro-Americano
    4. Native Hawaiian or Other Pacific Islander/
       Nativo Hawaiiano o Otra Isla de el Pacifico

    1. White / Blanco
    2. Don’t Know / No Sabe
    3. Refused/
       Se rehúsa a dar información
56. 8. Ethnicity – Check only one (1) / Origen Etnico – Marque uno de los siguientes (1):*

    1. Non-Hispanic / No-Hispano

    1. Hispanic /Latino / Hispano / Latino

    1. Don’t Know / No Sabe

    1. Refused / Se rehúsa a dar información
58. 9. Gender – Check only one (1) / Sexo – Marque uno de los siguientes (1):*

    1. Female/ Mujer
    2. Male/ Hombre
    3. Transgender M → F/ Transgénero H → M
    4. Transgender F → M/ Transgénero M → H

    1. Gender Queer/ Género Queer
    2. Other/ Otro
    3. Don’t Know/ No Sabe
    4. Refused/ Se rehúsa a dar información
60. Marital Status/Estado civil*

    1. Married/casado
    2. Single/soltero

    1. Widowed/viuda
    2. Divorced/divorciado

    1. Other/otro
62. 10. Family Type/Tipo de Familia – Check only one (1)/ Marque uno de los siguientes (1):*

    1. Single Parent Female/ Madre Soltera
    2. Single Parent Male/ Padre Soltero
    3. Two Parent Household/ 2-Padres de Familia

    1. Single Person/ Adulto Soltero
    2. Two Adults – NO Children/ 2 Adultos – NO niños
    3. Other/ Otro:
64. 11. Family Size – Number in Family / Miembros de la Familia – Familia Inmediata:*

    1. One (1) Person/ Una (1) Persona
    2. Two (2)/ Dos (2) Personas
    3. Three (3)/ Tres (3) Personas
    4. Four (4)/ Cuatro (4) Personas

    1. Six (6)/ Seis (6) Personas
    2. Seven (7)/ Siete (7) Personas
    3. Eight (8) or more/ Ocho (8) Personas
    4. Refused/ Se rehúsa a dar info
66. 12. Veteran Status – Have you been on Active Duty in the U.S. Armed Forces? – Check only one (1)
    Veterano de Guerra – Ha prestado servicio militar en las Fuerzas Armadas de los Estados Unidos – Marque uno de los siguientes (1):*

    1. No

    1. Yes/Si

    1. Don’t Know/ No Sabe

    1. Refused/ Se rehúsa a dar información
68. 13. Disabling Condition – Do you have a Disability or Disabling Condition? – Check only one (1):
    Condición Inválida – ¿Tiene usted una deseabilidad? Marque uno de los siguientes*

    1. No

    1. Yes/Si

    1. Don't Know/No Sabe

    1. Refused/ Se rehúsa a dar información
70. 14. Source and Amount of Income – How much did you earn from any of the following sources in the last 30 days
    Fuente y Cantidad de Ingreso – Cuanto dinero gano de las siguientes Fuentes en los ultimos 30 dias?: ($)
72. Earned Income / Salario Recibido*
73. 
    TDAP*
74. Unemployment Insurance / Desempleo*
75. Social Security /
    Seguro Social*
77. SSI / Seguro de ingreso suplementario*
78. Veteran’s Pension / Pensión de Veteranos*
79. SSDI / beneficios por incapacidad*
80. Pension from Job / Pension de Trabajo*
82. 
    Veteran’s Disability / Incapacidad de veteranos*
83. 
    Child Support / Manutencion de Hijos*
84. Private Disability Insurance / Seguro Privado de Incapacidad*
85. 
    Alimony / Manutención de Esposo(a)*
87. Worker’s Compensation / Compensación de los Trabajadores*
88. 
    
    TCA or TANF*
89. 
    
    Other / Otro:*
91. Total Monthly Income / Total de Ingresos mensuales: ($)*
92. ← ← How much did you earn last MONTH ?
    ← ← ¿Cuánto dinero gano el último MES ?
94. 15. 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.*

    1. No Schooling Completed/ No completo la escuela
    2. Nursery School to 4th Grade/ Jardin hasta cuarto grado
    3. 5th or 6th Grade/ Quinto o sexto grado
    4. 7th or 8th Grade/ Septimo a octavo grado
    5. 9th Grade/ Noveno grado
    6. 10th Grade/ Decimo grado
    7. 11th Grade/ Once grado
    8. 12thGrade, No Diploma/ Doce grado No Diploma

    1. High School Diploma/ Diploma de Secundaria
    2. GED/ Certificado equivalente a secundaria
    3. Jr College/universidad secundaria
    4. College/Universidad
    5. Graduate School/Escuela de posgrado
    6. Other/Ortro
    7. Don’t Know/ No Sabe
    8. Refused/ Se rehúsa a dar información
96. 16. Health Insurance – check or circle all health care benefits that you have:
    Seguro Médico – Marque todos los beneficios de asistencia medica que usted tiene:*

    1. Medical Assistance (MA) Health Choice / Asistencia Médica
    2. Maryland Children’s Health Program (MCHP) / Programa de salud para niños de Maryland
    3. Medicare
    4. VA Health Care/Medical Services / Seguro Medico para Veteranos
    5. Employer-Provided Health Insurance / Seguro de salud provistas por el empleador

    1. Health Insurance through COBRA / Seguro de salud a través de COBRA
    2. Private Pay Health Insurance / Seguro de salud pagado privado
    3. Don't know / No Sabe
    4. None / Ninguno
98. 17. Who could we contact in the event of an emergency / A quien podemos contactar en caso de Emergencia:
100. Name/Nombre:
101. Relationship/ Relacion:
103. Phone # 1/ # de telefono:
104. Phone # 2/ Otro #:
106. Other contact information or address for emergency contact/ Otro contacto o dirección en caso de emergencia:
108. 18. Family Members – Please list all family members that currently live with you:
     MIEMBROS DE LA FAMILIA – Por favor escriba todos los miembros de su familia que actualmente viven con usted:
110. Name – First/MiddleInitial/Last
     Nombre: Primero/Segundo/Apellido
111. Date of Birth (if known)
     Fecha de Nacimiento (si sabe)
112. Social Security Number (if known)
     Número de Seguro Social (si sabe)
113. Relationship/ Relacion
115. 1.
120. 2.
125. 3.
130. 4.
135. 5.
140. 6.
145. 7.
150. 8.
155. 9.
160. 10.
165. Referral Source/Fuente de referencia*

     1. Lender/Prestador
     2. RE Agent

     1. FCAA
     2. HUD

     1. Another Agency/otra agencia
     2. Friend/Relative/Amigo / pariente

     1. Other/Otro
167. CLIENT CONFLICT OF INTEREST DISCLOSURE STATEMENT
     
     The Frederick Community Action Agency 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 Frederick Community Action Agency 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 Frederick Community Action Agency, from lenders, developers, or other agencies with which Frederick Community Action Agency has a working relationship. You are under no obligation to use the products and/or services identified by the Frederick Community Action Agency, 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 Frederick Community Action Agency 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 Frederick Community Action Agency, 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 Action Plan that we develop together. This means to accomplish 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.
     
     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.
171. 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.
173. Client Signature*
174. Date*
176. Counselor Signature
177. Date
179. *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.
182. PRIVACY POLICY
184. The Frederick community Action Agency 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.
186. Types of information that we gather about you
     • Information we receive from you orally, on applications or other forms, such as your name, address, social security number, assets, debts, and income.
188. 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.
192. 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.
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194. 1. Receive an email copy of this form.
195. Email address

     This field is not part of the form submission.

196. Submit