Intake Form No CoApplicant

I understand that there is a $25 fee per household for materials.*
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:*
You must complete Workshop Day 1 on January 11 from 8:30 am - 12:30 pm before getting the Zoom Webinar link for Workshop Day 2 on January 18 from 8:30 am - 12:30 pm. Zoom webinar links will not be sent out until the week of the workshop.

Are you interested in purchasing a home in the City of Raleigh?*
- Yes
- No
Are you interested in purchasing a home in Wake County?*
- Yes
- No

First Name:*
Middle Initial:
Last Name:*
Suffix:
Address*
Address City State Zip Code
Home Phone
Work Phone
Cell Phone
You may call me on my:*
(Please make sure that this number is entered above)
Email:*
Preferred Language:

Services Required:
(Check all that apply)
- Education
- Homeowner Services
- Rental Counseling
- Homeless Services
- Home Purchase
- Mortgage Default/Early Delinquency
Referred by:*
Anticipated Date of Closing:
Month
Day
Year

Education*
Marital Status*
Active military?*
- Yes
- No
Are you a first time home buyer?*
- Yes
- No

Household Income*
County in Which You Currently Reside:*
Current Residence:*
Community/Property Name:*
How many years/months have you lived here?*
Is this a DHIC community?*
- Yes
- No

Social Security #
You have the option of waiting to give this information when you meet with a counselor.
Borrower's Monthly Income:*
Liabilities*
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:*
If you are unemployed or self-employed, then please list.
Start Date:*
Month
Day
Year
Number of years in profession?
Title:
Business Type:*
Gross Monthly Income:*
Net Monthly Income:*
Are you a full-time or part-time employee?*
- Full-time
- Part-time
Are you a farm worker?*
- Yes
- No

Employer's Address:*
Address City State 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.

Debt (Agency)	Monthly Payment	Current Balance

Gender	Age

Business Name & Address	Start/End Date	Income

Other Source of Income	Total Monthly Amount Received

Intake Form No CoApplicant

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