Client Registration Form


How did you hear about us?

How did you hear about us ? *

Workshop Information

Type of Event *

Participant Information

Include my contact information on lists distributed to other attendees.
Race *
Are you Hispanic? *
Do you live in a rural area ? *
Gender *
Veteran ? *
Head of household ? *
Foreign born ? *
Are you English proficient ? *
Disabled? *
Highest Level of Education *
Marital Status *
1st Time Homebuyer ? *
Residency Status *
1st Generation Homebuyer ? *

Additional Services Needed

Please indicate below, if you are in need of any additional services, by checking the boxes below.
All of the information that I/We have provided in this worksheet is correct and factual. No information has been withheld. We understand the necessity for accurate and complete information in obtaining a favorable workout / resolution. We will provide any needed information to assist the housing counselor. We understand that deliberately providing inaccurate information or an unwillingness to timely provide the counselor with the necessary information or documents to assist us can result in an adverse result. It will also result in closing of our file and no further assistance from the counselor will be provided.

Signature                                                                                                                                  Date
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Please ensure that all information above is accurate and true before clicking Continue. Your confirmation will be emailed to the individual and email address listed above.