Financial Fitness Intake

URL

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How did you hear about us? Who referred you?(Required)

PERSONAL INFORMATION – CLIENT

Your Name(Required)

Prefix First Middle Last

Veteran?(Required)

Yes

Your Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone

Work Phone

Cell Phone

SSN#(Required)

Birthday(Required)

Household Type:

Single adult

Married without children

Married with children

Two or more unrelated adults

Female-headed single parent household

Male-headed single parent household

Other

Household Type (Other)

# of people in household

Ages of dependent children

Is there a co-applicant?(Required)

Yes

PERSONAL INFORMATION | CO-CLIENT

Your Name

Prefix First Middle Last

Veteran?

Yes

SSN#

Birthday

INFORMATION FOR GOVERNMENT MONITORING PURPOSES

The following information is requested by the Federal Government for certain types of loans related to a dwelling in order to monitor the organization’s compliance with equal credit opportunity, fair housing and home mortgage disclosure laws. You are not required to furnish this information, but are encouraged to do so. The law provides that an organization may not discriminate either on the basis of this information, or on whether you choose to furnish it. If you furnish the information, please provide both ethnicity and race. For race, you may check more than one designation. If you do not furnish ethnicity, race, or sex, under Federal regulations, this organization is required to note the information on the basis of visual observation and surname if you have made this application in person. If you do not wish to furnish this information, please check the box below.

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I do not wish to furnish this informtion

Ethnicity

Co-Applicant Ethnicity

Race:

Co-Applicant Race:

Gender

Co-Applicant Gender

Education

Co-Applicant Education

Have a Disability

HOUSEHOLD FINANCIAL INFORMATION

Annual Family/Household Income (your total household income each year before taxes):

Estimated Annual Household Expenses (your total household expenses each year):

Total Outstanding Debt (including mortgages, credit cards, loans, etc.):

Employer:

Part-time

Full-time

Not Employed

ADDITIONAL QUESTIONS

Do you have any pressing financial concerns?

Findings from going over your budget:

Any additional comments or concerns:

How Can We Reach You?

We would love to chat with you. How can we get in touch?

Preferred Method of Contact

Best Time to Call You(Required)

AUTHORIZATION

Consent Name (Client)

Date (Client)

Consent Name (Co-Client)

Date (Co-Client

Financial Fitness Counseling Intake Form