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									                                      HOMEOWNER 201 REGISTRATION
      1803 Dorchester Avenue                                                                         Phone:617-265-8995
      Dorchester, MA 02124                                                                           Fax: 617-446-0117
                                    Email: info@mahahome.org                      Website: www.mahahome.org
      Class Location & Date_______________________________________________________________________
      Please complete application and submit/mail/fax to MA Affordable Housing Alliance

                       Participant Information                                         How did you learn about class?
    Name:                                                                                  Someone who took a class
    Address:                                                                               Agency/Organization
                                                                                           Lender/Mortgage Co.
    City                               State                   Zip
                                                                                           Friend/Relative
    Phone: [daytime]                                                                       Mailer/Flyer/Brochure
    Phone: [evening]                                                                       Internet
    Email:                                                                                 Newspaper
    Last 4 #SS                                                                             Other



1. Age:                                              2. Gender:                   Are you:
      20 - 30 yrs          40 - 50 yrs                  Male                   3. A Veteran?                                 Yes No
      31 - 40 yrs          51 - 60 yrs                  Female                 4. Disabled?                                  Yes  No
                                                                                  5. Head of Household?
                            60 + yrs                                                                                           Yes No
                                    7. Where were you born?                                                                       9.    What do you own?
                                                                                                                                  Single Family
    6. Ethnicity:                     U.S.                                        8. Do you own your home?
     Hispanic/Latino                                                                       Yes No                              2 Family
                                       U.S. Territory(e.g. Puerto                                                                3 Family
     Non-Hispanic/Latino           Rico)
                                                                                                                                  Condominium
                                      Other Country
                                                                                                                                  Other
    10. Race: (Please select one)                                                 11. How long have you been a homeowner?
     Single race categories:                                                           1 year or less
      American Indian or Alaskan Native                                               2 years
      Asian                                                                           3 years
      Black or African American                                                       4 years
                                                                                       5 or more years
      Native Hawaiian or other Pacific Islander
      White
                                                                                  12. What bank/lender holds your mortgage?
     Multi-race categories
      American Indian or Alaskan Native and White
     Asian and White
     Black or African American and White                                         13. Do you have a Soft Second Mortgage? Yes                            No
     American Indian or Alaskan Native     and Black or African
      American
     Other Multiple Race
    15. Insurance Company                                                         17. Household size:                                  18. Annual Household
        Insurance Agent                                                                                                                         Income:
        Premium                                                                       a. Number of adults
    16. Any homeowner claims in last 3 years?                                                                                                   $
                                                                                      b. Number of children
        Yes No         Claims for



MAHA OFFICE USE ONLY:
 Date Rec.         Counselor                 Postcard                       Database
MA Affordable Housing Alliance will use this information to evaluate the Homeowner 201 Education workshops and learn more about the
characteristics of who the program is serving. Information collected on this form is confidential.
                                Funding for these services provided by the City of Boston through its Department of Neighborhood Development,
                                                                          Thomas M. Menino, Mayor,
                                                                   Charlotte Golar Richie, Chief and Director
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