To better assist Neighborhood Housing Services of Greater Cleveland in evaluating your situations, please fill out ALL fields below. A staff member of Neighborhood Housing Services of Greater Cleveland will be in contact with you within 24 hours of completing the online form.

Neighborhood Housing Services of Greater Cleveland provides free, fair and unbiased assistance to all those seeking to achieve, preserve or sustain the American dream of homeownership. Remember, NEVER pay for a third party to intervene on your behalf before visiting a HUD-approved counseling agency, such as Neighborhood Housing Services of Greater Cleveland.

If you have any questions, please do not hesitate to contact us at 216.458.HOME (4663) or at info@nhscleveland.org.

Counseling intake date:	3/11/2010
Homeowner first name:
Homeowner last name:
Homeowner age:
Homeowner Race:	Unknown American Indian/Alaskan Native Asian Black or African American White American Indian/Alaskan Native and White Asian and White Black or African American and White American Indian/Alaskan Native and Black or African American Other
Homeowner Ethnicity Hispanic	YesNo
Homeowner Gender:	Male Female
Veteran:	YesNo
Household Type:	Single adult Female-headed single parent household Male-headed single parent household Married without children Married with children Two or more unrelated adults
Total houseHold size:	1 2 3 4 5 6 7 8+
Household Income (all family members’ gross income):
Address of property - do not use PO Box
Street number:
Street name:
City:
County:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Postal code:
Preferred Contact:	Home Phone   Work Phone Cell Phone
Home Phone:
Work Phone:
Cell Phone:
Email:
Name of originating lender (on down), if known:
Original loan number:
Name of current servicer:
Total monthly payment (PITI) at intake:
Type of first loan product at intake:	Fixed rate currently under 8% Fixed rate currently 8% or greater ARM currently under 8% ARM currently at 8% or greater Hybrid ARM (2/28 or 3/27) Option ARM Other Unknown
Is Loan
Interest only:	Yes No Unknown
FHA or VA fixed rate loan:	Yes No Unknown
FHA or VA ARM:	Yes No Unknown
Privately held:	Yes No Unknown
If Type of loan at intake is an ARM - has the interest rate already reset at least once?	Yes No Unknown
Primary reason for anticipated delinquency, delinquency, or default:	Reduction in income Poor budget management skills Loss of income Medical issues Increase in expenses Divorce/Separation Death of family member Business Venture Failed Increase in loan payment Other
Loan status at first contact:	Current 30 - 60 days late 61 - 90 days late 91 - 120 days late 120+ days late Unknown or Unsure