Registration
RequiredRequired Question(s)
Please provide the following information
 
1.
How many days are you delinquent on your Connecticut primary residential mortgage?
1 to 30 Days
31 to 60 Days
60 Days or More
2.

Are you delinquent on either of the following?

Property Taxes
Condo Fees
3.
Are you employed?

 

Yes
No
4.
Is your household income less than $120,000?

 

Yes
No
Required 5.

First Name

 

50 characters left.
Required 6.
Last Name
 

50 characters left.
7.

Email

 

50 characters left.
8.

Street Address 

 

50 characters left.
9.

City, State

 

50 characters left.
10.
Zip Code
 

50 characters left.
11.

Contact Phone Number in the format (555) 555-5555

 

50 characters left.
12.

Date of Birth 

 

50 characters left.
13.

Gender

Male
Female
14.
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
I choose not to answer
15.

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
16.

Marital Status

Married
Single
Separated
Divorced
Widow / Widower
Other
I choose not to answer
17.

Veteran

Yes
No
I choose not to answer
18.

How did you hear about us?

American Job Center (AJC)
Department of Labor (DOL)
CHFA
Housing Counseling Agency
Referral from Existing Client
Other