Application
RequiredRequired Question(s)
Please provide the following information
 
1.

Are you behind in your mortgage?

1-59 days
60-120 days
121 or more days
2.

Are you delinquent on your property taxes or condo fees?

Property Taxes
Condo Fees
Required 3.

First Name

 

50 characters left.
Required 4.
Last Name
 

50 characters left.
5.

Email

 

50 characters left.
6.

Street Address 

 

50 characters left.
7.

City, State

 

50 characters left.
8.
Zip Code
 

50 characters left.
9.

Home Phone in the format (555) 555-5555

 

50 characters left.
10.
Cell Phone in the format (555) 555-5555
 

50 characters left.
11.

Date of Birth 

 

50 characters left.
12.

Gender

Male
Female
13.
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
I choose not to answer
14.

Race

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Some Other Race
I choose not to answer
15.

Marital Status

Married
Single
Separated
Divorced
Widow / Widower
Other
I choose not to answer
16.

Veteran

Yes
No
I choose not to answer
17.

How did you hear about us?

Department of Labor/ American Job Center
CHFA
Housing Counseling Agency
Referral from existing client
Other