Homebuyer Intake Form

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Housing Services
Senior Housing
- Senior Housing Options
- Maintenance Department
845-225-8493
Contact
Contact

1 Applicant

2 Co Applicant

3 Additional Info

4 Worksheet

5 Privacy Policy

6 Opt-Out Election Form

7 Disclosure

8 Authorization

*Please be sure to fill out all questions and fields.
Applicant Name
First Last
Applicant Address
Street Address Address Line 2 City State ZIP Code
Applicant Home Phone
Applicant Work Phone
Applicant Cell Phone
Applicant Gender
- Male
- Female
- Other
Applicant Date of Birth
Applicant Soc. Security #
Applicant Email
Marital Status
Currently You:
- Own
- Rent
If Rent, How Long:
Housing Payment
Are you receiving Sect. 8:
- Yes
- No
Self-Employed:
- Yes
- No
Employer
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position
Years Employed
Please enter a number from 1 to 100.
Hire Date:
Date Format: MM slash DD slash YYYY
Annual Gross Income:
Source(s):

Co- Applicant Name
First Last
Co- Applicant Address
Street Address Address Line 2 City State ZIP Code
Co-Applicant Home Phone
Co-Applicant Work Phone
Co-Applicant Cell Phone
Co-Applicant Gender
- Male
- Female
- Other
Co-Applicant Date of Birth
Co-Applicant Soc. Security #
Co-Applicant Email
Co-Applicant Marital Status:
(Co-Applicant) Currently You:
- Own
- Rent
If Rent, How Long:
(Co-Applicant) Housing Payment
(Co-Applicant) Are you receiving Sect. 8?
- Yes
- No
(Co-Applicant) Self-Employed?
- Yes
- No
Co-Applicant Employer
(Co-Applicant) Employer Address
Street Address Address Line 2 City State ZIP Code
(Co-Applicant) Position
Years Employed
Hire Date
(Co-Applicant) Annual Gross Income
Source(s):

1. Total number of family members in household?
1a. Total additional income from household members over the age of 18:
2. Total number of family members in household under the age of 18
3. What amount do you currently have for down payment:
4. Have you or your Co-Applicant/Spouse owned a home within the last three (3) years of the date of this application?
- Yes
- No
4a. If “YES”, explain the circumstances under which you no longer own a home
5. Are you currently on the note and mortgage of deed of a property with someone else?
- Yes
- No
6. Applicant - Are you Disabled?
- Yes
- No
7. Co-Applicant - Are you Disabled?
- Yes
- No
8. **App Race (Head of Household)
- White
- Black or African American
- Asian
- Black or African American & White
- Hispanic & Black or African American
- Other Multi Racial
- Do not wish to disclose
8a. Hispanic?
- Yes
- No
- Do not wish to disclose
9. Active Military
- Yes
- No
Veteran?
- Yes
- No
Language
Education Level
10. Are you a U.S. Citizen(s)?
- Yes
- No
11. Please list your monthly debt / liabilities:
Specify Company, Balance Owed, Minimum Required Payment, & Status of Account for Each.
12. Have you ever been sued for a non-payment of a debt, had a garnishee against your wages or filed Bankruptcy?
- Yes
- No
If “YES”, Please explain:
13. Have you seen your credit report in the last 90 days?
- Yes
- No
If not, when?
Credit Score
14. Do you have any outstanding unpaid collection/charge off accounts?
- Yes
- No
How did you hear about us?
- TV / Radio
- HUD
- Print Media
- Friend / Relative
- Lender
Signature*
Name
First Last
Date
*Please be advised this is NOT an application to apply for financing or grant assistance. This is used for registration and demographics purposes only. ** The following questions are being asked for statistical purposes. Your answer will not affect, in any way, your enrollment for our programs.

Complete Budget

Use this worksheet to see how much money you spend this month. Then, use this month’s information to help you plan next month’s budget. Some bills are monthly and some come less often. If you have an expense that does not occur every month, put it in the “Other expenses this month” category.
Be sure to fill out all fields
Date (Month)
My income this month
Paychecks (salary after taxes, benefits, and check cashing fees)
Other income (after taxes) for example: child support
Total monthly income
My expenses this month
Housing
Rent or mortgage
Renter's insurance or homeowner's insurance
Utilities (like electricity and gas)
Internet, cable, and phones
Other housing expenses (like property taxes)
Food
Groceries and household supplies
Meals out
Other food expenses
Transportation
Public transportation and taxis
Gas for car
Parking and tolls
Car maintenance (like oil changes)
Car insurance
Car loan
Other transportation expenses
Health
Medicine
Health insurance
Other health expenses (like doctors' appointments and eyeglasses)
Personal and Family
Child care
Child support
Money given or sent to family
Clothing and shoes
Laundry
Donations
Entertainment (like movies and amusement parks)
Other personal or family expenses (like beauty care)
Personal and Family
Fees for cashier's checks and money transfers
Prepaid cards and phone cards
Bank or credit card fees
Other fees
Personal and Family
School costs (like supplies, tuition, student loans)
Other payments - credit cards
Other payments - credit cards
Other payments - credit cards
Other expenses this month
Total monthly expenses
Income-Expense=

Privacy Agreement*
I agree to the privacy policy.
Putnam County Housing Corporation is committed to assuring the privacy of individuals and/or families who have contacted us for assistance. We realize that the concerns you bring to us are highly personal in nature. We assure you that all information shared both orally and in writing will be managed within legal and ethical considerations. Your "non-public personal information," such as your total debt information, income, living expenses and personal information concerning your financial circumstances, will be provided to creditors, program monitors, and others only with your authorization and signature. We may also use anonymous aggregated case file information for the purpose of evaluating our services, gathering valuable research information and designing future programs.

Types of information that we may gather about you:

1. Information we receive from you orally, on applications or other forms, such as your name, address, social security number, assets and income;

2. Information about your transactions with us, your creditors, or others, such as your account balance, payment history, parties to transactions and credit card usage; and

3. Information we receive from a credit reporting agency, such as your credit history.

You may Opt-out of certain disclosures:

1. You have the opportunity to "opt-out" of disclosures of your nonpublic personal information to third parties.

2. If you choose to 'opt-out," we will not be able to answer questions from your creditors. If at any time you wish to change your decision with regard to your "opt-out," you may contact us.

Release of your information to third parties:

1. So long as you have not opted-out, we may disclose some or all of the information that we collect, as described above, to your creditors or third parties where we have determined that it would be helpful to you, would aid us in counseling you, or is a requirement of grant awards which make our services possible.

2. We may also disclose any nonpublic personal information about you or former customers to anyone as permitted by law.

3. Within the organization, we restrict access to nonpublic personal information about you to those employees who need to know that information to provide services to you. We maintain physical, electronic and procedural safeguards that comply with federal regulations to guard your nonpublic personal information.

I understand that my name and telephone number will not be shared with other parties, but that other information gathered may be used for research, program or policy development, or other legitimate purposes by the New York State Office of the Attorney General and parties with which it contracts (such as the Center for New York City Neighborhoods and Empire Justice Center), the City of New York, or other relevant funders of foreclosure prevention services.
Applicant Signature*
Name
First Last
Co-Applicant Signature
Name
First Last

Opt-Out Election Form-ONLY SIGN IF OPTING OUT*
Opt-Out Housing Counseling Privacy Disclosure
1. I understand that Putnam County Housing Corporation (PCHC) provides Housing Counseling with funding from the U.S. Department of Housing and Urban Development (HUD) and other state and federal agencies.

2. I understand as a part of funding requirements, some of my person information will be shared with program administrators or their evaluators

3. 1. I acknowledge that I have received a copy of Putnam County Housing Corporation’s Privacy Policy. I have elected to OPT-OUT of disclosures of my nonpublic personal information to third parties.
Applicant Signature*
Name
First Last
Co-Applicant Signature
Name
First Last

Comprehensive Housing Counseling Program Disclosure*
I agree to the Comprehensive Housing Counseling Program Disclosure
I/We understand that the purpose of the housing counseling program is to provide one-on-one
counseling to assist me/us with our counseling needs. The counselor will analyze my/our financial
situation, identify those barriers preventing me/us from resolving our current situation, and develop
a plan to remove those barriers. I/We further understand that it will not be the responsibility of the
counselor to fix the problem for me/us but rather to provide guidance and education to empower
me/us in fixing those issues. Type of services we provide are:
Mortgage Delinquency and Default Resolution Counseling
Provides counseling to homeowners at risk or in foreclosure
Pre-purchase Counseling
Preparing clients to become first time homebuyers
Rental Housing Counseling
Assists clients with their housing and financial situation
Reverse Mortgage Counseling
Provides statutory-required counseling to clients age 62 or older who are interested in
obtaining an FHA-insured HECM.
Services for Homeless Counseling
Counseling is provided to individuals needing information regarding emergency
shelters, transitional housing and referrals.
Pre-purchase Homebuyer Education
Partners with EHomeAmerica to provide online homebuyer education for a fee of $99.00

Funders include U.S. Department of Housing and Urban Development, New York State Attorney
General’s Office, the New York State Division of Housing and Community Renewal and the State
of New York Mortgage Agency.

Putnam County Housing Corporation offers the following services and has financial relationships
with following industry partners:
HUD Housing Choice Voucher Program (Section 8)
HUD Comprehensive Housing Counseling Program
NYS Attorney General’s Home Ownership Protection Program (HOPP)
SONYMA/NCC Restart Program
Family Self-Sufficiency Program (FSS)
Federal Home Loan Bank (FHLB) Homebuyer Dream Program with local partners:
Tompkins Mahopac Bank; M & T Bank; PCSB Bank; and Hudson Valley Federal Credit Union.
Lakeview Housing Development Fund
Gleneida Housing Development Fund
Gleneida Senior Apartments
Senior Housing at Mahopac Hills

I/We understand that Putnam County Housing Corporation provides information and education
on alternative services, programs and products. I/We further understand that we are not obligated to
receive any other services offered by the organization or its exclusive partners.
Applicant Signature*
Name
First Last
Co-Applicant Signature
Name
First Last

Authorization to Release Information*
I agree to release additional information to the PCHC in the future without further authorization.
I/We are working with the Putnam County Housing Corporation in Carmel, New York (a HUD certified counseling agency) (PCHC). I/We hereby authorize you to release any and all information concerning our account to the PCHC at their request. I/We further authorize you to discuss our case with Margherita Diaz or Suzanne Brought.
Applicant Signature*
Name
First Last
Co-Applicant Signature
Name
First Last
Untitled
- First Choice
- Second Choice
- Third Choice

11 Seminary Hill Road
Carmel, New York 10512
845-225-8493

Services

Free Foreclosure Help
Reverse Mortgage
Free Housing Counseling
Home Ownership
Home Improvement
Housing Choice Voucher
Maintenance Department

Office Hours

8:30 am to 4:30 pm
Monday – Friday

Homebuyer Intake Form

Complete Budget

My income this month

My expenses this month