NeighborImpact Personal Profile Intake Form

Participant Information
Full Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year

Home Address *

Street Address
Street Address Line 2
City	State
Zip Code	Country

Different Mailing Address?

Yes No

Mailing Address (If Different)

Street Address
Street Address Line 2
City	State
Zip Code	Country

County *
Primary Phone *

Area Code Phone Number
Type *

Land Line Cell Work
E-mail *
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NeighborImpact Program Disclosure
NOTE: If you have an impairment, disability, language barrier, or otherwise require an alternative means of completing this form or accessing information about financial, asset building, and/or homeownership services, please request alternative accommodations homesource@neighborimpact.org or 541-323-6567.

NeighborImpact and Program Purposes: NeighborImpact is a nonprofit, HUD approved comprehensive community action agency. The HomeSource Department offers counseling, coaching, and education on credit/budget management, financial capability, asset building, pre-purchase, reverse mortgages, loss mitigation, individual development accounts, homebuyer education/counseling, post-purchase, and financial literacy. NeighborImpact Weatherization program offers home rehabilitation services, NeighborImpact Lending department offers a series of loan products including down payment assistance, preservation loans, and small business loans. We serve all clients regardless of income, race, color, religion/creed, sex, national origin, age, family status, disability, or sexual orientation/gender identity. We administer our programs in conformity with local, state, and federal anti-discrimination laws, including the federal Fair Housing Act (42 USC 3600, et seq.). As a program participant, please affirm your roles and responsibilities along with the following disclosures. Initial, sign and date the form on the following page.

One-on-One Services Client and Coach/Counselor Roles and Responsibilities:

Coach/Counselor’s Roles and Responsibilities
- Review your housing and/or financial goal and your finances; which include your income, debts, assets, and credit history
- Prepare a Client Action Plan that lists the steps that you and your counselor will take in order to achieve your goal
- Review household budget and discuss options to manage your debt, expenses, and savings according to your goals
- Provide referrals to other agencies/services as appropriate
- Your counselor is not responsible for achieving your housing or financial goal, but will provide guidance and education in support of your goal
- Neither your counselor nor NeighborImpact employees, agents, or directors may provide legal advice
Client’s Roles and Responsibilities
- Complete the steps that you developed in conjunction with your counselor as stablished in your Client Action Plan
- Provide accurate information about your income, assets, debts, expenses, credit, and employment
- Attend appointments, return calls and email messages, provide requested paperwork in a timely manner
- Notify your counselor when changing goals
- Attend educational workshop(s) (i.e. homebuyer education workshop) as recommended
- Complete surveys and program evaluations
- Retain an attorney if seeking legal advice and/or representation
Termination of Services: Failure to work cooperatively with your counselor and/or NeighborImpact will result in the discontinuation of counseling services. This includes, but is not limited to, missing three appointments.
Participant Initials Acknowledging Termination of Services Clause *
Type Initials
Agency Conduct: No NeighborImpact employee, officer, director, contractor, volunteer, or agent shall undertake any action that might result in, or create the appearance of, administering counseling operations for personal or private gain, provide preferential treatment for any person or organization, or engage in conduct that will compromise our agency’s compliance with federal regulations and our commitment to serving the best interests of our clients.

Agency Relationships: NeighborImpact has financial affiliations with HUD, OHCS, NeighborWorks America, E-Home America, and FrameWork. NeighborImpact also has received donations from Umpqua Bank, JP Morgan Chase & Co, Bank of America Charitable Foundation Inc., Washington Federal Foundation, Wells Fargo Foundation, Brooks Resources Corporation, Hayden Homes, First Story, Central Oregon Association of Realtors and Oregon Association of Realtors Home Foundation. As a program participant, you are not obligated to use the products and services of NeighborImpact or our industry partners.

Alternative Services, Programs, and Products & Client Freedom of Choice: NeighborImpact lending department offers first-time homebuyer down payment assistance. However, you are not obligated to participate in this or other NeighborImpact programs and services while you are receiving housing and/or financial counseling from our agency. You may consider seeking alternative products and services, including those offered by the Federal Housing Administration (FHA), Oregon State first-time homebuyer loan programs, and/or United States Department of Agriculture (USDA) loans. A list of community resources is provided during your initial session and/or available anytime with our receptionist. You are entitled to choose any real estate professionals, lenders, and lending products that best meet your needs.

Referrals and Community Resources: You will be provided a community resource list which outlines many county and regional services available to meet a variety of needs related to your housing and financial goals. You may also be referred to other services of the organization or other agencies that may be able to assist you with particular concerns that have been identified. The Community Resources identifies alternative agencies that provide services, programs or products equivalent to those offered by NeighborImpact and its industry partners. You understand that you are not obligated to use any of the services offered to you.

Privacy Policy: I/we acknowledge that I/we received a copy of NeighborImpact’s Privacy Policy.
Participant Initials: I/we acknowledge that I/we received a copy of NeighborImpact’s Privacy Policy. *
Type Initials
Errors and Omissions and Disclaimer of Liability: I/we agree NeighborImpact, its employees, agents, and directors are not liable for any claims and causes of action arising from errors or omissions by such parties, or related to my participation in NeighborImpact counseling; and I hereby release and waive all claims of action against NeighborImpact and its affiliates. I have read this document, understand that I have given up substantial rights by signing it, and have signed it freely and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law. If any provision of this document is unenforceable, it shall be modified to the extent necessary to make the provision valid and binding, and the remainder of this document shall remain enforceable to the full extent allowed by law.

Quality Assurance: In order to assess client satisfaction, program evaluation, and in compliance with grant funding requirements, NeighborImpact, or one of its partners, may contact you during or after the completion of your housing counseling and/or financial capability services. You may be asked to complete surveys asking you to evaluate your client experience. Your survey data may be confidentially shared with NeighborImpact grantors such as HUD, OHCS, and/or NeighborWorks America.

I acknowledge that I received, reviewed and agree to NeighborImpact’s Program Disclosures.

I/We understand that any intentional or negligent representation(s) of the information contained on this form may result in civil liability and/or criminal liability under the provisions of Title 18, United States Code, Section 1001.
Electronic Signature Acknowledgement *

I acknowledge typing my name below serves as my electronic signature
Participant Signature *
Date

Month Day Year
Date
Co-Participant Signature
Date

Month Day Year
Date

Authorization-Privacy Policy
NeighborImpact (NI) 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 personal information shared both orally and/or in writing will be managed within legal and ethical considerations. Please carefully review this notice as it describes our policy regarding the collection and disclosure of your nonpublic, personal information. Your “nonpublic personal information” (information that identifies you personally and that is not otherwise publicly available 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. NeighborImpact has a client complaint policy. You can request a copy of it at any time from our agency or you can download it from our website www.neighborimpact.org/services.

TYPES OF INFORMATION WE GATHER ABOUT YOU
1. Information we receive from you orally, or on application 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, transactions and credit card usage; and
3. Information we receive from a credit reporting agency, such as your credit history and credit reports.
4. 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.
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 (such as your creditors), that is, direct us not to make those disclosures.
2. If you choose to “opt-out”, we will not be able to answer questions from your creditors or meet program compliance. If you choose to opt out, DO NOT SIGN UNDER THE RELEASE CLAUSE BELOW . You may change your “opt-out” decision at any time by contacting our agency.
3. If you choose to allow us to release your information as provided in this Privacy Policy, sign under the “RELEASE” clause below. If you later change your decision and wish to “opt-out” going forward, you must notify NeighborImpact in writing at homesource@neighborimpact.org . The opt-out will not apply to actions already taken based upon your prior consent.
RELEASE OF YOUR INFORMATION TO THIRD PARTIES
1. You understand and agree that NeighborImpact may disclose some or all of the personal information collected, as described above, to third parties that it determines would be helpful to you or will assist with your counseling needs. Examples of such entities including creditors, financial service providers, federal, state, local public agencies, non-profit partners, and/or any other pre-authorized individuals or organizations.
2. You understand and agree that NeighborImpact submits client level information to meet grant requirements, opens files to be reviewed for program monitoring and compliance purposes to agencies that support the operations and mission of NeighborImpact, including HUD, City of Bend, City of Redmond (CDBG funds), OHCS, and NeighborWorks America, including Project Reinvest and all other NeighborWorks America programs.
3. You give permission to grant administrators and/or their agents to contact you as needed within the next three years for program evaluation.
4. You understand that NeighborImpact may also disclose any nonpublic personal information to anyone as permitted by law (e.g., if NI are compelled by legal process).
RELEASE: I hereby authorize NeighborImpact to release nonpublic personal information as stated above. I acknowledge that I received a copy of NeighborImpact’s Privacy Policy, and that I have read and understood NeighborImpact’s privacy practices and disclosures.
Electronic Signature Acknowledgement *

I acknowledge that typing my name below serves as my electronic signature
Participant Signature *
Date *

Month Day Year
Date
Co-Participant Signature
Date

Month Day Year
Date

NeighborImpact Authorization to Obtain and Release Information
I hereby authorize the release/exchange of my information to and from NeighborImpact in order to assist with my case.

I authorize NeighborImpact to:
- Pull my (our) credit report(s) for all applicable services provided, at various times as needed.
- Obtain a copy of the final Closing Disclosure Statement, Appraisal, and Real Estate Note(s) when I purchase a home from the lender who made me/us a loan or the title company that closed the loan.
- Obtain a copy of the final Closing Disclosure Statement for the Home Equity Conversion Mortgage (HECM) from the lender who made me/us a loan or the title company that closed the loan.
This consent is voluntary and shall remain in effect until it is revoked or NeighborImpact’s services are complete. I further acknowledge that I may revoke this consent in writing at any time except to the extent that action based on this consent has already been taken.

I acknowledge that a copy or electronic reproduction of this form is as valid as the original.
Electronic Signature Acknowledgement

I acknowledge that typing my name below serves as my electronic signature
Participant Signature *
Date

Month Day Year
Date
Co-Participant Signature
Date

Month Day Year
Date
Questions? Call: (541)323-6567 between the hours of 8:30am and 4:30pm Mon-Fri or e-mail: homesource@neighborimpact.org
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NeighborImpact Personal Profile Intake Form

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