Pre-Purchase Home Buying Counseling Intake

Debt Counseling Corporation is both a HUD approved 501(c)3 nonprofit organization and a 501 (c)(3) nonprofit credit counseling organization.

To provide you with the most effective and efficient service, please complete the form below as thoroughly as possible. The more complete the paperwork is filled out, the more time we can devote to addressing your current financial situation.

Referral Source:

Prospective Homebuyer First Name * Last Name * Gender == select == Male Female Marital Status == select == Single Married Widowed Divorced Separated Street Address City State New York Zip/Postal Code Mailing Address (if different) City State New York Zip/Postal Code Date of Birth Social Security Number (once you have submitted this form, please call us at 1-888-354-6332 to give us this information) Home Phone Work Phone Fax Cell Phone Email Preferred Contact == select == Home Phone Work Phone Cell Phone Email Are you a U.S. Citizen? == select == Yes No Highest level of Education Completed == select == Elementary School High School Diploma GED Diploma Vocational Certificate Some College - Never Completed Associates Degree Bachelors Degree Masters Degree Doctoral Degree Country of Origin Select a Country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakstan Kenya Kiribati Kuwait Kyrgystan Lao Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia (FYR) Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Scotland Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe Ethnicity == select == Hispanic or Latino Non-Hispanic or Latino Race == select == White Black/African American Asian American Indian or Alaska Native Native American or Pacific Islander American Indian/Alaskan and Black/African American Asian and White American Indian/Alaska Native and White Unknown Other Foreign Born? == select == Yes No Do you have a Disability? == select == Yes No

Prospective Homebuyer (if applicable) First Name Last Name Gender == select == Male Female Marital Status == select == Single Married Widowed Divorced Separated Street Address City State New York Zip/Postal Code Date of Birth Social Security Number (once you have submitted this form, please call us at 1-888-354-6332 to give us this information) Home Phone Work Phone Fax Cell Phone Email Preferred Contact == select == Home Phone Work Phone Cell Phone Email Are you a U.S. Citizen? == select == Yes No Highest level of Education Completed == select == Elementary School High School Diploma GED Diploma Vocational Certificate Some College - Never Completed Associates Degree Bachelors Degree Masters Degree Doctoral Degree Country of Origin Select a Country Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakstan Kenya Kiribati Kuwait Kyrgystan Lao Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia (FYR) Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Scotland Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe Ethnicity == select == Hispanic or Latino Non-Hispanic or Latino Race == select == White Black/African American Asian American Indian or Alaska Native Native American or Pacific Islander American Indian/Alaskan and Black/African American Asian and White American Indian/Alaska Native and White Unknown Other Foreign Born? == select == Yes No Do you have a Disability? == select == Yes No

Total number of individuals in the household

Age:    Male   Female	Age:    Male   Female
Age:    Male   Female	Age:    Male   Female
Age:    Male   Female	Age:    Male   Female
Age:    Male   Female	Age:    Male   Female

Employment

Prospective Homebuyer Employer Employer's Address Start Date Yearly Salary $ Title/Position Paid == select == Weekly Bi-weekly Bi-monthly Monthly Paycheck Amount After Taxes $

Prospective Homebuyer (if applicable) Employer Employer's Address Start Date Yearly Salary $ Title/Position Paid == select == Weekly Bi-weekly Bi-monthly Monthly Paycheck Amount After Taxes $

Additional Income

Income	Prospective Homebuyer	Prospective Homebuyer (if applicable)
Alimony/Child Support	$	$
Social Security	$	$
Rental Income	$	$
Pension	$	$
Foster/Adoption Subsidy	$	$
Part Time Income	$	$
Other	$	$

Prospective Homebuyer's Outstanding Debt

	Monthly Payment	Current/Behind
Total credit card debt	$	$
Total car loans	$	$
Total student loans	$	$
Personal loans	$	$
Unpaid taxes	$	$
Other	$	$

Prospective Homebuyer's Outstanding Debt (if applicable)

	Monthly Payment	Current/Behind
Total credit card debt	$	$
Total car loans	$	$
Total student loans	$	$
Personal loans	$	$
Unpaid taxes	$	$
Other	$	$

Assets

Savings $	Checking $	401k/403b $
Anticipated purchase price $
Monies designated for down payment/closing costs? $
Have you owned a home in the past three years? Yes   No
Are you currently working with a Realtor? Yes   No
Are you in contract on a home? Yes   No
Have you applied/been approved for any local grants? Yes   No
If so, which ones?