Puede traducir este formulario con la bandera de idiomas en la esquina derecha.
If you require accommodation for impairment, disability, language barrier, etc., please email email@example.com call (541) 323-6567.
This is an initial intake form. Some services may require additional fees and/or documents. Please select all services you are interested in:
Please answer all the questions below
Page 1 of 8
Page 2 of 8
Page 3 of 8
Page 4 of 8
Please list the type(s) debt you have. Please list total debt for each item instead of monthly payment.
Page 5 of 8
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 firstname.lastname@example.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
Client’s Roles and Responsibilities
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.
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. – California, Neighborhood Reinvestment Corp. (Sun Trust Bank), Washington Federal Foundation, Wells Fargo Foundation, Brooks Resources Corporation, 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.
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.
Questions? Call: (541)323-6567 between the hours of 8:30am and 4:30pm Mon-Fri or e-mail: email@example.com
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
YOU MAY OPT-OUT OF CERTAIN DISCLOSURES
RELEASE OF YOUR INFORMATION TO THIRD PARTIES
I hereby authorize the release/exchange of my information to and from NeighborImpact in order to assist with my case.
I authorize NeighborImpact to:
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.
Page 7 of 8
Page 8 of 8