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					                                 HOMEOWNERSHIP COUNSELING AND SUPPORTIVE SERVICES
                                        PARTICIPATION DISCLOSURE NOTICE


This notice outlines the types of services available through HOME, Inc.’s Homeownership Counseling and
Supportive Services (hereinafter, Service), which is designed to assist Clients in purchasing their own homes.
This disclosure notice must be read and signed prior to participation in the Service as outlined below.

The Client understands that participation in the Service is voluntary. The Client may withdraw from the
Service at any time. HOME, Inc. shall provide the following assistance to the client:

   Interview and assessment to determine readiness to purchase a home.
   Development of a Homeownership Plan which outlines the actions required to become mortgage ready.
    The Plan will be developed upon client consent.
   Pre-purchase counseling is available to assist the client in implementing the actions outlined in the plan.
    The Client may also receive individual technical assistance on various aspects of purchasing a home on
    the open market including credit repair strategies, determining affordable housing costs,
    information on financing options, grant funds available and referrals to local lenders and
    community resources.

Upon completion of the above counseling services, the Client may apply for services of the HOME, Inc.
Property Program which include:

   Lease/purchase involves the acquisition, rehabilitation and permanent financing of properties that are
    rented with an option to purchase by the Client upon completion of all phases of homeownership
    counseling and supportive services.
   Turn Key involves the construction or major rehabilitation of properties (using subsidies for long term
    affordability) that are offered for purchase by clients completing counseling and becoming mortgage
    ready.

The Client understands that participation in the Property Program is based on meeting eligibility criteria and
program capacity. The Client further understands that making application for the Property Program is
voluntary and is not required in order to receive Homeownership Counseling and Supportive Services.

I/We do hereby certify that the information contained in this assessment is true and complete to the best of
my/our knowledge and belief.
I understand that there is an administrative fee of $20.00 for this service payable in advance to HOME, Inc.
(This payment is only accepted in the form of a money order or personal check, NO CASH)


Dated this _______________ day of _____________________________, ____________

__________________________________                                __________________________________
Applicant’s Signature                                             PRINT Applicant’s Name

__________________________________                                __________________________________
Co-Applicant’s Signature                                          PRINT Co-Applicant’s Name                    1
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  FOR OFFICE USE ONLY:                                                                                                      PY 0809
  __________          ______________                    SERVICE:
  INCOME %            DATE RECEIVED                      Assessment Only        Assessment & HOME, Inc. Property


                                HOMEOWNERSHIP READINESS QUESTIONNAIRE
APPLICANT’S NAME: _______________________________________________________________________________

CO-APPLICANT’S NAME:

PHONE: (home) _______________________(cell) ____________________ (day)________________________________

ADDRESS: (List former address if current address is less than one year)
Current:                                                      Former:
Street_____________________________________________           Street_____________________________________________
City___________________________________ Zip ________                        City_______________________________ Zip ____________
Length of Occupancy__________                  Own         Rent           Length of Occupancy_________              Own  Rent
Landlord Name______________________ Phone_________                          Landlord Name______________________ Phone_________

IF ARE YOU CURRENTLY USING A SECTION 8 VOUCHER FOR RENTAL OR HOMEOWNERSHIP
ASSISTANCE? (PLEASE CIRCLE ONE)

HOUSEHOLD MEMBERS:
APPLICANT NAME: ________________________________________________________ BIRTH DATE:______________
                 (Last, First, Middle)
CO-APPLICANT NAME: _____________________________________________________ BIRTH DATE:______________
                    (Last, First, Middle)
DEPENDANTS: _____________________________ AGE: ______ _____________________________ AGE: ______
            _____________________________ AGE: ______ _____________________________ AGE: ______
            _____________________________ AGE: ______ _____________________________ AGE: ______

MARITAL STATUS: Please check one of the following.
   Single  Married  Divorced, when? _____________  Legally separated, when? __________
   Other, please explain _________________________________________________________________________________

EMPLOYMENT HISTORY:
List employment for ALL adults providing financial support for the household. If employment is less than one year, provide
information for past employer.

APPLICANT:                                                                  CO-APPLICANT:
Current Employer __________________________________                         Current Employer _________________________________
Address ___________________________________________                         Address __________________________________________
Contact Person _____________________________________                        Contact Person ____________________________________
Phone _____________________ Hire Date _____________                         Phone _____________________ Hire Date _____________
Job Title___________________________________________                        Job Title___________________________________________
Past Employer _____________________________________                         Past Employer _____________________________________
Address ___________________________________________                         Address ___________________________________________
Contact Person _____________________________________                        Contact Person _____________________________________
Phone _____________________ Hire Date _____________                         Phone _____________________ Hire Date _____________
Job Title___________________________________________                        Job Title___________________________________________
                                                                                                                                2

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WHAT IS APPLICANT’S HIGHEST EDUCATION RECEIVED? ________________

FINANCIAL INFORMATION:

INCOME: Please list ALL sources of income. Please list your MONTHLY GROSS INCOME. Do you get paid weekly, bi-
weekly, bi-monthly, monthly or yearly?
                       SOURCE             MONHTHLY GROSS AMOUNT                  PAY-CYCLE


Employment:         ___________________           $______________ Monthly  Weekly  Bi-weekly  Bi-monthly  Yearly
                  ___________________             $______________ Monthly  Weekly  Bi-weekly  Bi-monthly  Yearly
Social Security: __________________              $______________
*Other:             __________________           $______________  Monthly  Weekly  Bi-weekly  Bi-monthly  Yearly
                    __________________           $______________  Monthly  Weekly  Bi-weekly  Bi-monthly  Yearly
(*Other income: child support, alimony, adoption subsidy, etc.)

ASSETS:        Please list all the following items.

TYPE OF                       NAME OF                                                               BALANCE/VALUE
ACCOUNT                       FINANCIAL INSTITUTION

Checking             _____________________________________________________________                  $_______________
Savings              _____________________________________________________________                  $_______________
Please check any of the following types of accounts held by members of the household.

                      Retirement Fund         401K       403B   Mutual Fund     IRA          Life Insurance

EXPENSES/LIABILITIES: Please list ALL re-occurring monthly expenses.
                                       MONTHLY PAYMENT                                                        MONTHLY PAYMENT
Nontraditional Credit:                                                            Traditional Credit:
Rent/Housing:                         $________________                           Savings:                  $ ________________
Utilities (Gas & Electric):             ________________                          Car Loan:                   ________________
Utilities (Water)                      ________________                           Car Loan:                   ________________
Phone:                                  ________________                          Student Loan:               ________________
Cable:                                  ________________                          Personal Loan:              ________________
Health Insurance:                      ________________                           Credit Card:                ________________
Auto Insurance:                         ________________                          Credit Card:                ________________
Life Insurance:                         ________________                          Other:                      ________________
Child Care:                             ________________
Child Support:                         ________________
Medical Expenses:                       ________________
Other:                                  ________________

How much do you expect to pay for a monthly house payment, including taxes and insurance? ______________

How soon do you hope to be mortgage ready? ________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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HOW DID YOU HEAR ABOUT OUR PROGRAM? (PLEASE CHECK ONE)
 AGENCY     AGENCY OUTREACH     HUD WEBSITE      LENDER                                   REAL ESTATE AGENT

RACE:
The following information is requested by the U.S. Department of Housing & Urban Development for monitoring purposes.
Please check the appropriate box below.
     American Indian or Alaska Native           American Indian or            American Indian or Alaska Native
        & Black or African American                  Alaska Native & White
     Asian                                      Asian & White                 Black or African American
     Black or African American & White          Native Hawaiian or            White
     Other Multiple Race                        Other Pacific Islander

ETHNICITY:
    Hispanic                 Non-Hispanic

PRIMARY LANGUAGE SPOKEN:




                                                   CREDIT AUTHORIZATION


Authorization is hereby granted to Home Opportunities Made Easy, Inc. (hereinafter “HOME, Inc.”) to
obtain a consumer credit report through a credit reporting agency chosen by HOME, Inc. I understand and
agree that HOME, Inc. intends to use the consumer credit report for the purpose of evaluating my financial
readiness to buy a home.

My signature below authorizes the release to the credit reporting agencies or any mortgage lender of
financial information which I have supplied HOME, Inc. in connection with its assistance in my obtaining
mortgage counseling.



______________________________________________                     _____________________________________________
Applicant’s Full Name (please print)                               Co-Applicant’s Full Name (please print)

______________________________________________                     _____________________________________________
Applicant’s Signature                                              Co-Applicant’s Signature

______________________________________________                     _____________________________________________
Social Security Number                                             Social Security Number

______________________________________________                     _____________________________________________
Date                                                               Date




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