Debt Counseling Corp.
3033 Expressway Drive North
Hauppauge, NY 11749
Phone: 1.888.354.6332
Email info@debtcounselingcorp.org

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
Marital Status
Street Address
City
State
Zip/Postal Code
Mailing Address (if different)
City
State
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
Are you a U.S. Citizen?
Highest level of Education Completed
Country of Origin
Ethnicity
Race
Foreign Born?
Do you have a Disability?
Prospective Homebuyer (if applicable)
First Name
Last Name
Gender
Marital Status
Street Address
City
State
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
Are you a U.S. Citizen?
Highest level of Education Completed
Country of Origin
Ethnicity
Race
Foreign Born?
Do you have a Disability?


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
Paycheck Amount After Taxes
$
Prospective Homebuyer (if applicable)
Employer
Employer's Address
Start Date
Yearly Salary
$
Title/Position
Paid
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?
Prospective Homebuyer Electronic Signature By clicking this box, you agree to the above mentioned terms. Your computer's IP address (54.164.198.240) will be recorded. Date
Prospective Homebuyer Electronic Signature (if applicable) By clicking this box, you agree to the above mentioned terms. Your computer's IP address (54.164.198.240) will be recorded. Date

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