Community Action Partnership of Suburban Hennepin 8800 Hwy 7 Suite 401, St. Louis Park, MN 55426 Counseling Application Checklist Please complete all of the following pages, attach the required documents and submit to: **Incomplete applications will result in delayed response. Community Action Partnership can make a copy of any documents you may need. 1. ____ This Packet: Complete and Current 2. ____ Copies of your most recent monthly bills. (Including all utilities, credit cards, mobile phone, etc.) 3. ____ Letter stating reason for mortgage default and/or hardship. Including Loan # and address. Must be signed and dated – see sample letter. 4. ____ Complete copy of last two bank statements for all accounts. (Please copy all pages even if pages are blank- Online Activity Summaries are not acceptable.) 5. ____ Copy of Income Verifications from all sources for the past two months. (Paycheck Stubs, Benefit Statements and Award Letters Etc.) 6. ____ Copy of current Mortgage Statement and ALL recent contacts/communications with Mortgage Company and/or Attorney. Include: Second Mortgage, Home Equity Line of Credit and Notice of Sheriffs Sale. 7. ____ A copy of your most recent Federal Tax Return. Must be signed and dated (even if e-filed) and include all schedules and W2’s 1 of 21 CAPSH FPCA 7.29.2013
Transcript
Community Action Partnership of Suburban Hennepin
8800 Hwy 7 Suite 401, St. Louis Park, MN 55426
Counseling Application Checklist Please complete all of the following pages, attach the required documents and submit to:
**Incomplete applications will result in delayed response. Community Action Partnership can make a copy of any documents you may need.
1. ____ This Packet: Complete and Current
2. ____ Copies of your most recent monthly bills. (Including all utilities, credit cards, mobile phone, etc.)
3. ____ Letter stating reason for mortgage default and/or hardship. Including Loan # and address. Must be signed and dated – see sample letter.
4. ____ Complete copy of last two bank statements for all accounts. (Please copy all pages even if pages are blank- Online Activity Summaries are not acceptable.)
5. ____ Copy of Income Verifications from all sources for the past two months. (Paycheck Stubs, Benefit Statements and Award Letters Etc.)
6. ____ Copy of current Mortgage Statement and ALL recent contacts/communications with Mortgage Company and/or Attorney. Include: Second Mortgage, Home Equity Line of Credit and Notice of Sheriffs Sale.
7. ____ A copy of your most recent Federal Tax Return. Must be signed and dated (even if e-filed) and include all schedules and W2’s
1 of 21 CAPSH FPCA 7.29.2013
–FORECLOSURE PREVENTION ASSISTANCE PROGRAM INTAKE FORM
Agency / Organization Newspaper Internet Mailer / Flyer / Brochure Friend / Relative Realtor Someone who took a workshop Lender / Mortgage company Other: _____________________
2. Your ethnicity: Hispanic Non-Hispanic
3. Your race: (Please select only one) Single Race
American Indian / Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
4. How many people live in the house? __________
Multiple Race American Indian / Alaskan Native & White American Indian / Alaskan Native & Black Asian & White Black or African American & White Native Hawaiian/Other Pacific Islander & Black Other multiple race: _______________________
5. Your gender: Male Female Co-Applicant Gender: Male Female
6. For immigrants and refugees only: Please indicate where you were born:
Asia Africa Europe North America South America
7. Is this a female-headed household? Yes No
(tax filing status as single female household with dependent children) 2 of 21
CAPSH FPCA 7.29.2013
8. Please check the highest education level you have completed: 8th grade or less Some college or trade school Bachelor’s degree
Some high school Associates degree Graduate or professional degree High school diploma / GED
9. Your marital status: Married Divorced Single Widow/Widower
10. In what county do you currently reside? ____________________________________
11. What is your current housing: Rent Own Staying with family / friends
12. Were you a first time home buyer? Yes No (You did not own a home for three years before you bought this house)
13. Are you a first generation home buyer? Yes No(Your parents did not own a home.)
STATUS
14. How far behind are you on your mortgage payments? $ _________________ # months ___________________
15. Family Type: Single (No children) Two+ Adults, With children Two+ Adults, No children Single Parent – Female Single Parent – Male
16. Please explain what led to you falling behind on your mortgage payments:
Chapter 7 Date you filed: _______ / _______ / _______
17. Have you ever filed bankruptcy? Yes No
17a. If yes, what kind? Chapter 13
18. Did you receive pre-purchase education or counseling prior to purchasing your home? Yes No
18a. If yes, with which organization? ___________________________________________
PROPERTY
19. Type of Property:
Co-op Manufactured home – Own land Manufactured home – Do not own land
20. Date purchased: _________Purchase Price: $ ____________Refinanced: Date:___________Amount$__________
Multiplex (two or more units) Townhome / Condo Single family (house)
Excellent Fair Poora. Condition of Home: Good 3 of 21
CAPSH FPCA 7.29.2013
21. Income. Please include income for you and the Co-Applicant only from all sources (Work, disability payments, child support, investment income, etc.)
Name (Person receiving Source of Income income) Employer/Dates
Full-time or
part-time
Number
hours
worked per
week
Gross
(before taxes)
Monthly
Amount
Net
(after taxes)
Monthly Amount
FT / PT FT / PT FT / PT FT / PT
If you require additional space, please check here, and use the back of this page
22. Last year’s gross annual income (before-tax income for entire household): $ _____________________
23. Please list all other household members currently living in the house. Do not include applicant or co-applicant:
Name
Relationship (To applicant)
Gender
Age Source of income (Job, food stamps, Social Security, etc.)
Gross monthly income (Contribution to household) (Before Taxes)
$ $ $
Net monthly income (After Taxes)
$ $ $
Race (See question #3 for categories)
Full-time student (Living at home)
Yes No Yes No Yes No
If you require additional space, please check here, and use the back of this page
24. What payments are you in default with?
Contract for Deed Homeowners Association Dues Homeowners Insurance Mechanics Lien Property Taxes Mortgage Other: _______________________________________
25. Has a Sheriff’s sale been set? Yes No Date: ______________________
INCOME
FAMILY
HOUSING
4 of 21 CAPSH FPCA 7.29.2013
26. Information about your Mortgage/Contract for Deed. Please fill out as completely as possible: (If you currently hold more than two mortgages or Contracts for Deed, please copy this page and attach that information as well).
Mortgage Info:
Mortgage Company (Name)
Mortgage Type: (Please contact Fannie Mae at 1-800-732-6643 or Freddie Mac at 1-800-373-3343 if you are unsure. For FHA please contact your lender)
Account Number
Street Address of Company
City, State & Zip of Company
Contact Person’s Name
Contact Person’s Phone Number
Contact Person’s Fax Number
Monthly payment amount
Does payment include property taxes?
Does payment include homeowners insurance?
Loan was used for:
Interest Rate
Is your interest rate fixed or adjustable (circle one)
When did the mortgage company last accept a payment from you?
Have you ever fallen behind in your mortgage payments before?
Are you currently, or have you ever been, in a repayment program with your mortgage company?
First Mortgage / Contract for Deed
Check One: Fannie Mae FHA
Freddie Mac Other
(
(
$
)
)
Yes
Yes
No
No
To buy the house Second mortgage: (you did not pay off your 1st mortgage) to get cash, payoff credit cards, repair house, etc. Down payment, closing cost assistance at time you bought the house. Refinance: Paid-off a prior mortgage and it may include money to pay off credit cards, cash or home repairs, etc.
%
Fixed / Adjustable
/ / (mm / dd / yy)
$_________________ How much was the payment?
Yes No
Date ______________
Yes No
Date ______________
2nd Mortgage / Contract for Deed
Check One: Fannie Mae FHA
Freddie Mac Other
(
(
$
)
)
Yes
Yes
No
No
To buy the house Second mortgage: (you did not pay off your 1st mortgage) to get cash, payoff credit cards, repair house, etc. Down payment, closing cost assistance at time you bought the house. Refinance: Paid-off a prior mortgage and it may include money to pay off credit cards, cash or home repairs, etc.
%
Fixed / Adjustable
/ / (mm / dd / yy)
$_________________ How much was the payment?
Yes No
Date ______________
Yes No
Date ______________
5 of 21 CAPSH FPCA 7.29.2013
____________________
(________________________ $_____________
________________________ $_____________
________________________ $_____________
ASSETS
27. Statement of assets. As head of household, I declare that members of my household have no ownership, full or part, of any assets other than those identified below, the value of which has been disclosed:
ITEM VALUE
Cash on hand over $100.00 Yes No $_______________
Checking / Savings Accounts Yes No $ _______________
Certificates of Deposit Yes No $ _______________ Maturity Date: _____________
Annuities Yes No $ _______________
Stocks / Bonds / Mutual Funds Yes No $ _______________
IRA / 401k / Retirement Funds Yes No $ _______________ Early withdrawal penalty?
Whole Life Insurance Policy Yes No $ _______________ yes no
Other Real Estate Yes No $ _______________ (Exclude current property)
Businesses Yes No $ _______________
Other* (example: Boat/cabin). Yes No $ _______________ Loan balance:
Other* Yes No $ _______________ Loan balance:
Other* Yes No $ _______________ Loan balance: * Other items may include snowmobiles, boats, antiques, recreational vehicles and other luxury items.
If you require additional space, please check here and use the back of this page
28. Monthly household Budget:
Monthly Amount Past Expense Category Amount Balance Creditor Due
Mortgage 1 $ $ $
Mortgage 2 $ $ $
Association Dues $ $ $
Property Taxes-Not escrowed $ $ $
Property Insurance-Not escrowed $ $ $
Food $ $ $
Electricity $ $ $
Gas / Heat $ $ $
Phone/Cell $ $ $
Water $ $ $
Garbage $ $ $
Auto 1 __________________________ $ $ $ Make Model Year
6 of 21 CAPSH FPCA 7.29.2013
29. Monthly household Budget (Continued):
Monthly Amount Past Expense Category Amount Balance Creditor Due
Auto 2 __________________________ $ $ $ Make Model Year
Auto Insurance $ $ $
Gas (Automobiles) $ $ $
Bus/Public Transportation $ $
Health Insurance(not deducted) $ $ $
Medical Expenses $ $ $
Child Care $ $ $
Child Support / Alimony $ $ $
Credit Card 1: _____________ $ $ $
Credit Card 2: _____________ $ $ $
Credit Card 3: _____________ $ $ $
Student Loans $ $ $
Loan 1: __________________ $ $ $
Loan 2: __________________ $ $ $
Donations / Tithes / Offerings $ $ $
TV / Cable / Satellite $ $ $
Entertainment/Eating Out $ $
Clothing $ $
Other: ____________________ $ $ $
Other: ____________________ $ $ $
Other: ____________________ $ $ $
Other: ____________________ $ $ $
Other: ____________________ $ $ $
If you require additional space, please check here and use the back of this page
7 of 21 CAPSH FPCA 7.29.2013
30. Scams:
a. Did anyone contact you offering assistance to modify your mortgage, either directly by telephone, or by other means such as by mail or a flyer? Yes No
b. Were you guaranteed a loan modification or asked to do any of the following: Pay a fee, sign a
contract, redirect mortgage payments, sign over title to your property, or stop making loan payments. Yes No
31. Client Contribution:
Your mortgage company may have several options to assist you in becoming current or remaining current on your mortgage. The majority of programs will require some type of contribution from you, with greater amounts the further behind you are.
If you are currently not making payments, you need to set aside those funds for future payments. This will help you demonstrate to your mortgage company that you can make future payments.
We understand your future financial situation may be uncertain, but please provide us with an estimate for the following, otherwise please check “cannot estimate”:
Contribution you could make now: $______________In 30 Days: $_______________OR
Cannot Estimate
Source of contribution (future paychecks, sale of asset, help from relatives, etc.
I/We certify that the statements contained in this application are true, accurate and complete to the best of
my/our knowledge and belief. I/We hereby authorize the release of any information necessary for this
organization to process this application.
Applicant Signature Co-Applicant Signature Date
8 of 21 CAPSH FPCA 7.29.2013
National Foreclosure Mitigation Counseling
Program/Making Home Affordable
Outreach and Intake Project Combined
Privacy Act Notice And Tennessen Warning
NFMC/MHA Combined Privacy Act Notice and Tennessen Warning 1 of 2 05/01/2013
Counseling Organization Client First Name Client Last Name
We are committed to ensuring 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 the limitations of law. Please read carefully the disclosures and acknowledgements.
Social Security Numbers
The Privacy Act of 1974 makes it unlawful for any Federal, State, or local government agency to
deny your participation in the National Foreclosure Mitigation Counseling program (NFMC Program)
or the Making Home Affordable Outreach and Intake Project (MHA Project) if you refuse to provide
your social security number. If you do not voluntarily provide your social security number services
to you may be more limited, but you will continue to be eligible to receive the services we can
provide without a social security number.
Other Private Data
Under Minnesota Statutes, your name and address are public data. All other data we may ask
about you is private data on individuals. Except for your social security number, providing and
agreeing to share your private data is mandatory for participation in the NFMC Program or the MHA
Project under the terms of the federal grant from NeighborWorks that funds the program. If you do
not agree to allow us to share the data with the entities identified below, we will not be able to
provide services under the NFMC Program or the MHA Project.
We will share the data only with the following entities or their representatives for the purposes of
program management, compliance monitoring, and program evaluation:
Staff of this organization who need it to work on your case.
United States Department of Treasury, administering the MHA Project.
NeighborWorks America, the entity mandated by either Congress for the NFMC Program or
selected to administer the MHA Project by Treasury to account for how the program funds are
used and determine the program’s effectiveness, or its authorized representatives.
The Minnesota Housing Finance Agency, the recipient of the grant for the NFMC Program and
the MHA Project.
The Minnesota Home Ownership Center, a contractor of the Minnesota Housing Finance Agency
responsible for assisting program administration and reporting to NeighborWorks America under
the NFMC Program. Hope LoanPort, a web-based tool that streamlines home retention applications on behalf of
homeowners at-risk of foreclosure. Any other entities properly authorized under law to view it.
If you agree to allow us to collect and share information as described above, please indicate your
approval with your signature, below.
Client must sign if Information was provided by face-to-face counseling session.
9 of 21 CAPSH FPCA 7.29.2013
jgarrison
Placed Image
NFMC/MHA Combined Privacy Act Notice and Tennessen Warning 2 of 2 05/01/2013
Print Client Name Client Signature Date
Print Client Name Client Signature Date
Verbal Authorization is permissible if information was provided to client by non face-to-face
counseling session.
The undersigned verifies that verbal authorization for release of above confidential information has
been given. The client was fully informed of the information contained herein and understood its
nature and intended use of the released information. A copy of this notice with counselor’s
signature has been mailed to the client.
Client Name Date Counselor’s Signature
Sharing Data with Creditors
Sharing some of your personal financial information with creditors may be necessary to effectively
help you resolve your financial difficulties. If you agree that we may share private data, such as
information on your total debt, income, living expenses and personal information concerning your
financial circumstances with your creditors, program managers, and staff working on your case,
please indicate your approval by signing below.
Client must sign: If information was provided by face-to-face counseling session.
The undersigned has been fully informed of and understands the information contained herein, and
authorizes release of above confidential information.
Print Client Name Client Signature Date
Print Client Name Client Signature Date
Verbal Authorization is permissible if information was provided to client by non face-to-face
counseling session.
The undersigned verifies that verbal authorization for release of above confidential information has
been given. The client was fully informed of the information contained herein and understood its
nature and intended use of the released information. A copy of this notice with counselor’s signature has been mailed to the client.
Client Name Date Counselor’s Signature
Note to Counselor: If the client chooses not to sign this form or provide verbal authorization, the Counselor
may not provide NFMC Program or MHA Project counseling services.
10 of 21 CAPSH FPCA 7.29.2013
jgarrison
Sign Here
jgarrison
Sign Here
jgarrison
Sign Here
jgarrison
Sign Here
National Foreclosure Mitigation Counseling Program/Making Home Affordable
Outreach and Intake Project Foreclosure Mitigation Counseling Agreement/Disclosure Form
NFMC/MHA Foreclosure Mitigation Counseling Agreement/ Disclosure Form 1 05/01/2013
I understand that provides foreclosure
mitigation counseling after which I will receive a written Action Plan consisting of
recommendations for handling my finances, possibly including referrals to other housing agencies as appropriate.
I understand that receives Congressional
funds through the National Foreclosure Mitigation Counseling (NFMC Program) and United States Department of Treasury (Treasury) funds through the Making Home Affordable Outreach and Intake Project (MHA Project) and it is required to share some
of my personal information with the entities as described and acknowledged in the “Combined Privacy Act Notice and Tennessen Warning,” for the purposes of program
monitoring, management, compliance, and evaluation.
I understand that a counselor may answer questions and provide information, but not
give legal advice.
I understand that, in addition to foreclosure mitigation counseling,
also provides the following types of services:
I understand that is required to fully disclose
potential and actual conflicts of interest so that I am in a position to make fully informed
decisions.
I understand that or one of its foreclosure
mitigation counselors may have one of the following conflicts through referral or in fact:
We hold or service a mortgage secured against your property and have a stake in the performance of the loan;
We purchase, redevelop, and sell, for a fee, properties at risk of, or involved in foreclosure;
We receive financial support from mortgage servicer or investor. Payment may be based on acceptance of a loss mitigation offer.
Other (Specify)
jgarrison
Placed Image
NFMC/MHA Foreclosure Mitigation Counseling Agreement/ Disclosure Form 2 05/01/2013
I understand that I may be referred to other services of the organization or another
agency or agencies as appropriate that may be able to assist with particular concerns that have been identified. I understand that I am not obligated to use any of the
services offered to me.
I acknowledge that I have received a copy of the Combined Privacy Act Notice and
Tennessen Warning. If you choose to not sign or verbally acknowledge the Combined Privacy Act Notice and Tennessen Warning, your counselor may not provide NFMC
Program or MHA Project services.
I acknowledge that ______________________, NeighborWorks America, and Treasury may conduct follow-up with me related to program evaluation.
Please check here if you do not want to be contacted by __________________, NeighborWorks America and Treasury for program evaluation purposes only. By
checking this box you are only opting out of being contacted for program evaluation.
Client must sign if information was provided by face-to-face counseling session.
Print Name of Client Client’s Signature Date
Print Name of Client Client’s Signature Date
Verbal Authorization is permissible if information was provided to client by non face-to-face counseling session.
The undersigned verifies that the client was fully informed of the information contained herein and understood its nature. The client has given verbal authorization and
acknowledgement. A copy of this notice with counselor’s signature has been mailed to the client.
Client’s Name Date Counselor’s Signature
Note to Counselor:
If the client chooses not to sign this form or provide verbal authorization, the Counselor may not provide NFMC Program or MHA Project services.
COMMUNITY ACTION PARTNERSHIP OF SUBURBAN HENNEPIN (CAPSH) 8800 Highway 7, #401 St. Louis Park, MN 55426
Phone: 952-933-9639 Fax: 952-933-8016
Your Privacy Rights This Notice describes Community Action Partnership of Suburban Hennepin’s (“CAPSH”) policy regarding collection and disclosure of personal information and tells you about your rights under the Minnesota Government Data Practices Act (“the Act”). The Act protects your privacy, but also lets us give information about you to others if a law requires it AND we tell you before we do it, or if you agree to let us provide that information. This Notice tells why and when CAPSH will ask for and give out information about you.
What kind of information do we collect? Under the Act, information about people is divided into four areas: Public: information about you that is available to anyone. Your name and address are public data, and can be released
without your consent. Private: information about you that can be shared only if you give us your permission or if a law allows or requires us to share
the information. Confidential: information about you that can’t be shared with you. Summary: information that does NOT identify you personally. Summary information is used to report about CAPSH’s
services to all clients. Generally, CAPSH only asks for two types of information from you – public and private. All other data we may ask about you is private data on individuals. CAPSH uses summary information for reports does not identify you or anyone else by any type of identifying information.
Why do we ask you for this information? We may ask you for information so we can: Tell you from other persons with the same or similar name Determine if you can receive services from us, what services you can receive, and any limits to those services Help you get financial or social services from others Make reports, do research, audits, and evaluate our programs
We collect private information about you to assist in providing you: (check all that apply) Homebuyer education Homebuyer counseling Reverse Mortgage counseling Home Maintenance and Rehab counseling Other: (client/s must initial:)
Do you have to provide the information we request? What will happen if you do not?
Generally, you do not have to give us private information. However, if you do not provide private information (such as income, debts, and assets) services to you may be more limited, we may not be able to determine whether we can help you, or get help for you from others. The Privacy Act of 1974 makes it unlawful for any Federal, State, or local government agency to deny your participation in these housing counseling programs if you refuse to provide your social security number. If you do not provide your social security number services to you may be more limited, but you will continue to be eligible to receive services we can provide without a social security number.
Who can get the information CAPSH has about you? We may give private information about you to the following agencies or organizations, if they need it to help you or help us help you. This does not mean we always share information about you with these agencies or organizations. It means that we may share your private information with those listed without your consent (sometimes we MUST share certain information). If you have questions about when we give these people information, ask the CAPSH employee who is working with you. MN Department of Human Services, MN
Department of Commerce, or MN Housing Finance Agency
US Dep’t. Housing & Urban Development or US Department of Health and Human Services
Hennepin County; the city in which you reside
MN Homeownership Center, Family Housing Fund
Anyone under contract with us or a government agency, in order to provide services or administer programs
Banks, financial institutions or other organizations that have information about a current or possible mortgage
Credit bureaus or creditors Other government agencies who have or may
provide you with help Landlords, rental property managers Any government agency or organization that
laws say we can or must give information
You have the right to copies of information we have about you.
You may ask CAPSH if we have any information about you and ask for copies. You may give other people permission to see and have copies of information about you (this permission must be in writing). If you do not understand the information CAPSH has on or about you, you may ask to have it explained to you. You may ask for and receive a copy of CAPSH’s Data Practices policy.
How do you appeal if you think information is not accurate or complete?
If you think CAPSH’s information about you is not correct, you can write to CAPSH to explain why. You may deliver it in person or mail it to: Community Action Partnership of Suburban Hennepin
Attn: APPEALS OFFICER 8800 Highway 7 Suite 401 St. Louis Park, MN 55426
You must say why the information is not accurate or complete. You may send your statement of the facts with which you disagree. Your statement will be attached when CAPSH’s information about you is shared with others.
If you have any questions about the information on this form, ask the CAPSH employee who is working with you or contact CAPSH’s Director of Planning & Development at 952-697-1325.
I acknowledge that I have received this Notice and understand and agree to its content. Name: Signature: Date: Name: Signature: Date:
This Notice is available in other languages and other formats upon request.
Verbal acknowledgement is acceptable if information was provided to client in non face-to-face counseling session. The undersigned verifies that verbal acknowledgement has been given. The client was fully informed of the information contained herein and understood its nature. _______________________________ _____________________________ Client’s Name Counselor’s Signature Date NOTE TO COUNSELOR:, we recommend sending a copy of the Combined Privacy Act Notice to clients who have given verbal acknowledgement of this notice. At a minimum, clients must provide public data (i.e. name and address) to receive HECAT services. If a client refuses to provide public data the Educator/Counselor may not provide HECAT services.
14 of 21 CAPSH FPCA 7.29.2013
jgarrison
Sign Here
jgarrison
Sign Here
Foreclosure MitigationCounseling
Agreement/Disclosure Form
I understand that Community Action Partnership of Suburban Hennepin (CAPSH) provides foreclosure mitigation counseling. After which, I will receive a written Action Plan consisting of recommendations for handling my finances, possibly including referrals to other housing agencies as appropriate.
I understand that CAPSH receives funds through the Minnesota Housing Finance Agency and the Minnesota Home Ownership Center and is required to share some of my personal information with the Minnesota Housing Finance Agency, the Minnesota Home Ownership Center or their agents and other entities as described and acknowledged in the “Combined Privacy Act Notice and Tennessen Warning,” and “Your Privacy Rights” for the purposes of program monitoring, management, compliance, and evaluation.
I acknowledge that I have received a copy of the “Combined Privacy Act Notice and Tennessen Warning” and “Your Privacy Rights.”
I understand that a counselor may answer questions and provide information, but not give legal advice. If I want legal advice, I will be referred to appropriate assistance.
I understand that CAPSH provides information and education on numerous loan products and housing programs and I further understand that the counseling I receive from CAPSH in no way obligates me to choose any of these particular loan products or housing programs
I understand that I may be referred to other services of the organization or another agency or agencies as appropriate that may be able to assist with particular concerns that have been identified. I understand that I am not obligated to use any of the services offered to me.
I understand that CAPSH is required to fully disclose potential and actual conflicts of interest so that I am in a position to make fully informed decisions. I understand that CAPSH or one of its foreclosure counselors may have the following conflict in fact:
Receive financial support from mortgage servicer or investor. Payment may be based on acceptance of a loss mitigation offer.
I understand that I am not obligated to receive services from the organization, the mortgage servicer or investor and have the right at any time to accept or decline any loss mitigation offer.
CAPSH and its counselors will provide services in good faith and attempt to find workable solutions to my housing situation; I understand, however, that depending on my circumstances, the solutions available may not be what I expected. In consideration of CAPSH’s assistance in resolving my housing situation, I agree to hold CAPSH, its directors, officers, employees and agents harmless for any losses, claims, liabilities or damages that may arise from CAPSH’s provision of services.
Verbal Authorization is permissible if information was provided to client by non face-to-face counseling session.
The undersigned verifies that the client was fully informed of the information contained herein and understood its nature. The client has given verbal authorization and acknowledgement.
___________________________________ _________________________ ___/___/___ Client’s Name Counselor’s Signature Date
NOTE TO COUNSELOR: EVEN IF INFORMATION WAS REVIEWED DURING A TELEPHONE COUNSELING SESSION, YOU MUST STILL MAIL A COPY OF THE “FORECLOSURE MITIGATION COUNSELING AGREEMENT” TO CLIENT.
8800 Highway 7, Suite #401 St. Louis Park, MN 55426
952-933-9639 www.capsh.org
HOUSING AND RELATED PROGRAMS: DISCLOSURE STATEMENT
Community Action Partnership of Suburban Hennepin (CAPSH) is approved by the US Department of Housing and Urban Development (HUD) and the Minnesota Housing Finance Agency to provide housing counseling services. You may be receiving services or information about First Time Home Buyer, Reverse Mortgage (HECM), Foreclosure Prevention, Home Rehab and Maintenance, Transitional Housing/Homelessness, Asset Development and/or Budgeting. Your services may be through one-on-one counseling or a workshop. All CAPSH services are provided in accordance with state and federal law.
During workshops, speakers and material may be presented from the private sector. This information is provided in a neutral manner, to inform participants of the types of services available. This is in no way intended to be an endorsement or recommendation of any specific company, agency, product or service. In providing all of its services, CAPSH is acting as a neutral third party. Additionally, during counseling, participants may receive lists of potential vendors, brokers, mortgage companies, banks and similar services. This is for informational purposes only, and is in no way intended to be an endorsement or recommendation of any specific company, agency, product or service. You, the participant/client, are free to choose any lender, loan product, home, provider or service that you want. While affordable homes, lending products and other forms of assistance may be available through CAPSH and/or its partners, you are under NO obligation to use these services. Decisions to use any provider, lender or other related service or program, is your decision alone, and CAPSH will not try to influence your decision in any way.
Please sign below to indicate that you have read the above information, understand it and have received a copy of this Statement.
Signature Date
Signature Date
If signing as a representative for a client, please indicate relationship:
CAPSH HUD Conflict Form (rev. 04/10)
17 of 21 CAPSH FPCA 7.29.2013
jgarrison
Sign Here
______
______
______
______
______
______
______
______
______
______
Community Action Partnership of Suburban Hennepin (“CAPSH”)
AUTHORIZATION TO RELEASE INFORMATION NAME OF MORTGAGE COMPANY
Name of Investor (If Known)
PHONE FAX ( ) ( )
Return
info
to:
Counselor:____________________________
Direct Phone:_________________________
Direct Fax: ___________________________
HUD Approved Housing Counseling Agency8800 Hwy 7, Suite 401St. Louis Park, MN 55426952-933-9639 Front Office
I authorize CAPSH to speak with and discuss my loan on my behalf with the lender and mortgage servicer named above, as well as with the owner of he mortgage loan (such as Fannie Mae or Freddie Mac).
I authorize YOU to release and/or share with CAPSH the information checked below (MUST be checked prior to signature AND initialed by client): Initial
My name, address and phone number
My social security number (Please list last four digits of your Social Security Number___________
The names, dates of birth and social security numbers of my children
My MFIP provider, case number, training or employment plan
Information on resources, benefits and services I receive from YOU or YOUR programs
Lender information, and information about my credit, including expenses, income and money I owe
Information about my housing payments and history (rented or owned)
Mortgage account and/or loan information: Account or Loan #
Property Address:
Other (Foreclosure and/or bankruptcy Attorney Name and Number):
I understand that information CAPSH has about me may be given to or shared with people or organizations according to the CAPSH Privacy Rights Notice I received from CAPSH.
The information requested will be used to help me: Obtain emergency assistance, transportation, housing and other basic needsX Receive homeownership services (pre- and post-purchase services) Other:
I understand that I am not required to authorize release of information. I also understand that I will not be denied assistance for refusing to agree to release the information requested. However, CAPSH may not be able to provide or obtain assistance for me if I do not agree.
I understand this Release will expire one (1) year after I have signed it. I also understand that I can cancel this Release at any time but this will not affect information released before I cancelled my consent.
Signature of Participant(s): / Date Printed Name(s): / Name of person signing for participant: Reason Unable to Sign: Signature of person who explained this form and your rights:
18 of 21 CAPSH FPCA 7.29.2013
jgarrison
Sign Here
COMMUNITY ACTION PARTNERSHIP OF SUBURBAN HENNEPIN (CAPSH) Request for Disclosure of Credit Bureau File Information
Applicant Spouse (If Requesting a Joint Credit Report) First Name MI Last Name First Name MI Last Name
Date of Birth (MM/DD/YYYY) Date of Birth (MM/DD/YYYY)
Home Phone Alternate Phone Home Phone Alternate Phone
I am the person named above and I understand that federal law provides that a person who obtains information from a consumer reporting agency under false pretenses shall be fined not more than $5,000 or imprisoned not more than one year, or both. I understand that by signing this form, my credit report will be delivered to a location other than my residence. By signing this form, I also authorize disclosure of my credit report to: CAPSH, 8800 Highway 7, Suite 401, St. Louis Park, MN 55426.
I understand that this Request for Disclosure will expire one (1) year after I have signed it. I also understand that I can cancel this Request for Disclosure at any time, but this will not affect any information released before I cancelled my consent.
I hereby authorize CoreLogic Credco, LLC (“CREDCO” or “FAC”) to obtain my consumer report/credit information, credit risk scores and other enhancements to my consumer report (hereinafter collectively referred to as “Report”) from one or more of the three national credit repositories (Equifax, Experian, Trans Union) and provide a copy of the Report to my housing counseling agency, Community Action Partnership of Suburban Hennepin (CAPSH) [“Counselor”] for Counselor to provide housing counseling services. This authorization is intended to comply with a consumer report request as set forth in 15 U.S.C. 1681b(a)(2).
I acknowledge that the Report is provided “AS IS” AND THAT CREDCO MAKES NO REPRESENTATION OR WARRANTY, EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO, IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE AND IMPLIED WARRANTIES ARISING FROM A COURSE OF DEALING OR A COURSE OF PERFORMANCE WITH RESPECT TO THE ACCURACY, VALIDITY, OR COMPLETENESS OF THE REPORT OR THAT IT WILL MEET MY NEEDS AND CREDCO EXPRESSLY DISCLAIMS ALL SUCH REPRESENTATIONS AND WARRANTIES.
I recognize that the accuracy, validity or completeness of the Report provided by CREDCO is not guaranteed by CREDCO and I hereby release CREDCO and CREDCO’s parent, sister, affiliated companies, successors and assigns and its and their directors, officers, agents, employees and independent contractors (collectively, “CREDCO’s Affiliates”) from any liability for any negligence in connection with the preparation of the Report and from any loss, damages, expenses, costs or obligations of any kind and nature whatsoever suffered by me resulting directly or indirectly from the inaccuracy, invalidity or incompleteness of the Report.
I covenant not to sue or maintain any claim, cause of action, demand, cross action, counterclaim, third party action or other form of pleading against CREDCO or CREDCO’s Affiliates for damages based upon the inaccuracy, invalidity or incompleteness of any Report provided by CREDCO hereunder.
If one or more of the provisions, or a portion of a provision of this document are held for any reason to be invalid, illegal or unenforceable, such invalidity or illegality or unenforceability will not affect any other provisions of this document, and this document will be construed as if such invalid, illegal or unenforceable provision had not been contained herein.
To order a joint credit report, you must be married. Both signatures are required if a joint report is requested.
Signature Signature
Date Date
CAPSH Request for Disclosure of Credit Bureau Information Revised 09/2011
19 of 21 CAPSH FPCA 7.29.2013
20 of 21 CAPSH FPCA 7.29.2013
jgarrison
Sign Here
jgarrison
Sign Here
8800 Hwy 7 Suite 401, St. Louis Park, MN 55426
Homeowners Association Verification
Last Name First Name Middle
Property Address City State Zip
Please check one:
Yes My property is part of a Homeowners Association. * Please attach Home Owners Current Statement
Association Name
No My Property is not part of a Homeowners Association.
