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Intake Form No CoApplicant
Step
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I understand that there is a $25 fee per household for materials.
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If you choose to pick up the course materials, please pick them up from the DHIC Homeownership Center, Monday - Friday between 8:30AM - 4:30PM. The office is located at 450 E. Davie Street, Raleigh NC 27601.
I understand and accept.
I would like to attend the following virtual Homebuyer Education Workshop:
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You must complete Workshop Day 1 on September 14 from 8:30 am - 12:30 pm before getting the Zoom Webinar link for Workshop Day 2 on September 21 from 8:30 am - 12:30 pm. Zoom webinar links will not be sent out until the week of the workshop.
September 14 & 21, 2024
Are you interested in purchasing a home in the City of Raleigh?
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Yes
No
Are you interested in purchasing a home in Wake County?
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Yes
No
First Name:
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Middle Initial:
Last Name:
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Suffix:
Address
*
Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip Code
Home Phone
Work Phone
Cell Phone
You may call me on my:
*
(Please make sure that this number is entered above)
Home Phone
Work Phone
Cell Phone
Email:
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Preferred Language:
Services Required:
(Check all that apply)
Education
Homeowner Services
Rental Counseling
Homeless Services
Home Purchase
Mortgage Default/Early Delinquency
Referred by:
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Anticipated Date of Closing:
Month
Day
Year
Race & Ethnicity:
*
(Choose one)
American Indian/Alaskan Native
Black or African American
Native Hawaiian or Other Pacific Islander
White/Caucasian
Asian
More than one Race
I choose not to respond
Are you Hispanic?
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Yes
No
What is your gender?
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Male
Female
Other/Non-conforming with the gender options
Age:
*
Date of Birth
*
Month
Day
Year
Number in household:
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Household Type
*
Female-Headed Single Parent
Male-Headed Single Parent
Married with Dependents
Married without Dependents
Single Adult
Two or more unrelated adults
Other
Are you Head of Household?
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Yes
No
Foreign born?
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Yes
No
Are you a veteran?
*
Yes
No
Are you disabled?
*
Yes
No
Do you have a disabled dependent?
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Yes
No
Rural area?
*
Yes
No
Are you proficient in English?
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Yes
No
Education
*
--
None
High School/GED
Primary School
2-year Vocational Training
Associates Degree
Bachelors Degree
Masters Degree
Above Masters
Marital Status
*
--
Married
Seperated
Divorced
Widow
Single
Active military?
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Yes
No
Are you a first time home buyer?
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Yes
No
Household Income
*
County in Which You Currently Reside:
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Current Residence:
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Rent
Own
Other
Community/Property Name:
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How many years/months have you lived here?
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Is this a DHIC community?
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Yes
No
Social Security #
You have the option of waiting to give this information when you meet with a counselor.
Borrower's Monthly Income:
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Liabilities
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Please list any debts you have, including: rent, credit cards, auto loans, student loans, childcare expenses, etc. *DO NOT LIST ANY UTILITIES.* Existing homeowners, please also include monthly payment (principle, interest, taxes, insurance, HOA dues), along with mortgage loan balance.
Debt (Agency)
Monthly Payment
Current Balance
Please list ALL dependents by gender and age:
*
Example: Daughter, 7; Daughter, 12; Son, 17; Mother, 87
Gender
Age
Present Employer:
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If you are unemployed or self-employed, then please list.
Start Date:
*
Month
Day
Year
Number of years in profession?
Title:
Business Type:
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Gross Monthly Income:
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Net Monthly Income:
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Are you a full-time or part-time employee?
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Full-time
Part-time
Are you a farm worker?
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Yes
No
Employer's Address:
*
Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip Code
Employer Contact Phone Number:
List previous full-time and/or part-time employment:
*
(Need the last three years of employment)
Business Name & Address
Start/End Date
Income
Other Sources of Income
*
Please list any additional sources of income (if NONE, then please type NONE in the first row). Other sources of income would include child support, disability, pension, overtime, and/or commissions.
Other Source of Income
Total Monthly Amount Received
Liquid Assets:
*
(Please check all that may apply)
N/A
Checking Account
Savings Account
CDs
Securities (stocks, bonds, etc.)
Retirement
Other Assets
What is the total amount of liquid assets?
*
Authorization
*
I authorize DHIC, Inc. Homeownership Center to: (a) pull my credit for pre-purchase counseling, post-purchase counseling, foreclosure prevention counseling or financial capability services; (b) obtain a copy of the Closing Disclosure, Credit Report, Appraisal, Loan Application and Promissory Note(s) from the client, lender, realtor or the title company that closed the loan; (c) provide information to lenders, HUD, NeighborWorks® America, and other agencies in connection with my application for mortgage financing. Such information includes, without limitation, credit history, employment history, bank statements, pay stubs, income tax returns and information regarding the property being purchased; and (d) contact me at the address, telephone number(s) and email address(es) provided this form. I understand that any intentional or negligent representation(s) of the information contained on this form may result in civil liability and/or criminal liability under the provisions of Title 18, United States Code, Section 1001.
Comments
This field is for validation purposes and should be left unchanged.
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