Orange County
Rural Development Advisory Corporation
www.ocrdac.org
Practical Mortgage Navigation:
Second Chance Foreclosure Education Partnership
Triage Assessment Form
The goal of the Practical Mortgage Navigation program by Orange County Rural Development Advisory
Corporation (RDAC) – a HUD APPROVED counseling agency -- is to educate and counsel on options and resources
to empower you to make an informed financial decision for your personal housing situation.
The Second Chance Foreclosure Education Partnership is a specially-focused partnership to
provide educational and other services in the context of a current or potential mortgage foreclosure.
What county do you live in?______________________________________________________
Name(s)_____________________________________________________________________
Mailing Address_______________________________________________________________
Email Address________________________________________________________________
Best phone number to reach you at________________________________________________
How many months are you in arrears?___________# of Co Applicants____________________
Have you declared bankruptcy?________________# of People in the house_______________
Do you have a sale date?_____________________ Annual Income______________________
Do you have a date of a settlement conference?______________________________________
How did you hear about our services?______________________________________________
Ethnicity: ______Hispanic ___________Non-Hispanic
Single Race Multiple Race
__American Indian / Alaskan Native __American Indian / Alaskan Native & White
__Asian __American Indian / Alaskan Native & Black
__Black or African American __Asian & White
__Native Hawaiian or Other Pacific Islander __Black or African American & White
__White __Native Hawaiian/ Pacific Islander & Black
__Undisclosed __Other multiple race: __________________________
PO Box 149, 232 Ward Street, Montgomery, NY 12549 (Phone) 845.457.4622 (Fax) 845.457.4655