(PLEASE CHECK DESIRED PROGRAM)Client Information Form



Dear Prospective Homeowner, Date: ________________Thank you for choosing Neighborhood Housing Services of Baltimore for your home purchase and financial needs! You are taking important steps toward sustainable homeownership. To request an individual counseling appointment with a certified Homeownership Advisor, we ask that you provide information to us about you and your home purchase plans. A one-on-one counseling session is required for all potential homebuyers looking to gain down payment and closing cost assistance from Baltimore City, the State of Maryland and all counties in Maryland. Please note – one-on-one counseling must be completed BEFORE submitting a contract on any property that you are requesting closing cost assistance from Baltimore City, Baltimore County and most other counties.Please return the completed intake packet, with all requested documents to the attention of the Intake Team via email to housingadvisor@ or 410-505-1237 and mail to 25 East 20th Street, Baltimore, Maryland 21218. No walk-ins until further notice.We will also need income, asset and liability information as listed below in the counseling documents checklist in addition to the signed authorization forms starred. Upon receipt of these documents, your Homeownership Advisor will contact you to schedule an appointment for your counseling session. The enclosed NHS of Baltimore Privacy Policy, Complaint, Conflict of Interest Policies and Resource Referral are provided for your information. Please retain these documents for your records.Counseling Documents Checklist? Paystubs for last 60 days? W2 for last 2 years? Federal tax returns filed for last 2 years with all attachments (submit pages 1-12)? If self-employee – last 3 years tax returns with all attachments (profit and loss statement to date)? Checking and savings account statements for last 3 months (all pages)? Credit Report Fee – $24.55 Individual Report; $49.10 Joint Report (Payable through PayPal or check or money order payable to NHS of Baltimore, Inc.) Please include credit report receipt with your packet? Driver’s license or state issued photo ID? NHSB Disclosure? Hold Harmless and Authorization form? Authorization to obtain Credit Report? Completed Budget? CFPB Questionnaire? Lead Paint Warning Statement? Release Form and Referral FormSincerely,Homebuyer Education DepartmentNeighborhood Housing Services of Baltimore, Inc.January 2020(PLEASE CHECK DESIRED PROGRAM)Client Information Form? Pre-Purchase? Fast Track Financial CoachingAPPLICANTCO-APPLICANTCUSTOMER INFORMATIONFull Name ___________________________________Full Name ___________________________________SSN _________________DOB __________________SSN _________________DOB __________________Address (Street) ______________________________Address (Street) ______________________________(City, St, Zip) _________________# of Years _____(City, St, Zip) _________________# of Years _____Home _______________Cell _________________Home _______________Cell _________________Email _______________________________________Email _______________________________________Gender: ?Male ? FemaleUS Citizen: ? Yes ? NoGender: ?Male ? FemaleUS Citizen: ? Yes ? NoVeteran: ? Yes ? NoDisabled: ? Yes ? NoVeteran: ? Yes ? NoDisabled: ? Yes ? NoEducation: ? College ? High SchoolEducation: ? College ? High SchoolMarital Status: ? Married ? Single ? DivorcedMarital Status: ? Married ? Single ? DivorcedDemographics:? American Indian/Alaskan Native? Asian? Black or African American? Native Hawaiian/Other Pacific Islander? White? American Indian/Alaskan Native/White? Asian and White? Black/African American and White? Amer. Indian/Alaskan Native and Black? Other? Choose not to answerHispanic Ethnicity ? Yes ? No (please select answer)Demographics:? American Indian/Alaskan Native? Asian? Black or African American? Native Hawaiian/Other Pacific Islander? White? American Indian/Alaskan Native/White? Asian and White? Black/African American and White? Amer. Indian/Alaskan Native and Black? Other? Choose not to answerHispanic Ethnicity ? Yes ? No (please select answer)EMPLOYMENT INFORMATIONEmployer ___________________________________Employer ___________________________________Occupation _________________________________Occupation _________________________________Income $ _______?Weekly ? Biweekly ?MonthlyIncome $ _______?Weekly ? Biweekly ?MonthlyStart Date ____________Years in Profession ____Start Date ____________Years in Profession ____Secondary Employer __________________________Secondary Employer __________________________Income $ ____________Years in Profession ____Income $ ____________Years in Profession ____HOUSEHOLD INFORMATIONMonthly Rent $ _____Head of Household ? Y ? NMonthly Rent $ _____Head of Household ? Y ? N# of People ____Ages _______________________# of People ____Ages _______________________HOME PURCHASE INFORMATIONDo you have a ratified contract of sale? ? Yes ? NoAre you seeking Closing Cost and Down Payment assistance? ? Yes ? NoAre you seeking to purchase in ? Baltimore City or ? Baltimore CountyProperty Address ___________________________________________________________________________Title Company ______________________________________________________________________________Phone Number ____________________Settlement Date __________Loan Officer ______________________Company _______________________________________________Phone Number ____________________Fax ____________________Realtor __________________________Company _______________________________________________Phone Number ____________________Fax ____________________Signature Required Below ? I/We authorize NHS of Baltimore to obtain the HUD1 closing statement information and to share counseling information with your current mortgage lender (s) and/or mortgage servicer(s).? I/We received a copy of the NHS of Baltimore, Inc. Privacy Policy, Disclosure, Hold Harmless/Authorization Agreement, Complaint Policy and Conflict of Interest Policy, Lead Warning Statement, Housing Counseling Agency Referral ListApplicant ____________________________________Signature ____________________________________Co-Applicant _________________________________Signature ____________________________________Date ______________HOUSEHOLD BUDGETING WORKSHEETTotal Monthly Gross Income$ _______Total Monthly Net Income$ _______Housing ExpensesRent or 1st Mortgage Payment$ _______Rent or 2nd Mortgage Payment$ _______Utilities$ _______Condominium/HOA Fee$ _______Renter’s Insurance$ _______Water/Sewer (Monthly)$ _______Auto ExpensesCar Payment$ _______Gas$ _______Insurance$ _______Maintenance$ _______Tolls, EZ Pass, Parking$ _______DebtsCreditor #1$ _______Creditor #2$ _______Creditor #3$ _______Creditor #4$ _______DiscretionaryChurch, Tithes, & Offerings$ _______Charitable Contributions$ _______Groceries$ _______Lunches, Meals Out$ _______Childcare$ _______School Tuition/Supplies$ _______School Activities$ _______Medical Bills & Co-Pays$ _______Prescription Medicines$ _______Pet Supplies & Vet Exams$ _______Entertainment$ _______Newspaper/Magazine Subscriptions$ _______Cable$ _______Landline Phone$ _______Cell Phone$ _______Internet$ _______Clothing$ _______Personal Care Items$ _______Hair Care, Nails, Etc.$ _______Gifts, Holidays$ _______Membership, Union Dues$ _______Other$ _______Monthly Expenses TotalsHousing Expenses$ _______Auto Expenses$ _______Debts$ _______Discretionary$ _______Total$ _______MONTHLY SURPLUS/SHORTAGETotal Monthly Net Income$ _______TIP: The monthly Surplus is the amount available for savings. If there is a shortage or break even, you must reduce your discretionary spending. Purchasing at an affordable level, setting goals and establishing reserve savings for emergencies and unexpected changes in income is the key to sustaining home ownership.Minus Total Monthly Expenses$ _______Equal Monthly Surplus/Shortage$ _______BALTIMORE CITY COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAMFAMILY/HOUSEHOLD INCOME VERIFIABLE CERTIFICATIONInformation on your annual family or household income is required to determine your eligibility to benefit from some Community Development Block Grant (CDBG) Program assisted activities. Each applicant is required to provide information regarding the number of persons in their family or household including respective total annual gross income. Information provided is subject to verification by representatives of the City of Baltimore and the U.S. Department of Housing and Urban Development (HUD).NOTE: “Income” is the total annual income of all family or household members as of the date of application. Income of all persons in the family or household must be included in calculating family or household income whether or not all family or household members receive assistance. Estimate the annual income by projecting the prevailing rate of income of each person at the time assistance is provided for the family or household. Report all income sources that you would include on a federal income tax return.INSTRUCTIONS:Circle the number of persons in your family or household (adults and children, including you).Within the selected column circle the income limit that is closest to your family or household gross income but it is NOT LESS THAN your family or household income. Note that household income includes the monies earned and/or benefits received by all household members.Sign and date the bottom to certify your family or household size and income.FEDERAL FISCAL YEAR 2020 – CDBG APPLICABLE INCOME LIMITS EFFECTIVE JULY 1, 2020BALTIMORE CITY MEDIAN FAMILY INCOME$104,000INCOME LIMIT CATEGORY?1 Person?2 Person?3 Person? 4 Person? 5 Person? 6 Person? 7 Person? 8 PersonExtremely Low Income (30% of Median)?$21,850?$25,000?$28,100?$31,200?$33,700?$36,200?$38,700?$41,200Low Income (50% of Median)?$36,400?$41,600?$46,800?$52,000?$56,200?60,350?$64,500?$68,650Moderate Income (80% of Median)?$54,950?$62,800?$70,650?$78,500?84,800?$91,100?$97,350?$103,650Over 80% of Median Income? Over$54,950? Over$62,800? Over$70,650? Over$78,500? Over$84,800? Over$91,100? Over$97,350? Over$103,650Source: U.S. Department of Housing and Urban Development. Data found at STATEMENT: By signing this form, I certify that the information given on this form is true and accurate to the best of my knowledge. I am aware that there are penalties for willfully and knowingly giving false information as an applicant for federally funded assistance or services, which may include immediate repayment of funds received and/or prosecution City, HUD or other Federal agencies and the Federal False Claims Act, 31 U.S.C. §3729 ET. seq. Upon request, I agree to provide supporting documentation on my family or household gross income including sources.Applicant Name (Please Print): _________________________________________________________________Current Address: ______________________________________________________Zip Code: ___________Applicant Signature: ___________________________________________________Date: _______________NEIGHBOROOD HOUSING SERVICES OF BALTIMORE DISCLOSURE STATEMENTNeighborhood Housing Services of Baltimore is a nonprofit organization with a mission to create and sustain homeownership in the Baltimore metro region. To assist residents and potential resident of Maryland, we offer the following products and services.Lending ProductsHome Buyer EducationPre-purchase CounselingPost-Purchase EducationTax Sale Foreclosure Prevention ServicesFast Track Financial CoachingThese products are available to any customer that requests them; however, NHS of Baltimore, Inc. does not mandate that any client utilize any service other than those specified during intake. Clients are not obligated to receive any other services offered by the organization or its exclusive partners.CLIENT STATEMENTI have read the above mentioned disclosure and understand that I am under no obligation and have not been steered toward any of the above products or services.________________________________Signature_____________Date___________________________________Print Name________________________________Signature_____________Date___________________________________Print Name________________________________Counselor Signature_____________DateHOLD HARMLESS AGREEMENT AND AUTHORIZATIONI (we) agree to hold harmless and indemnify Neighborhood Housing Services of Baltimore, Inc. and its employees, member officers and directors in connection with acts performed by them which would reasonably be associated with consultation, technical advice, financial counseling, loan processing, property inspection, construction management and other related activities.I (we) further agree to indemnify, hold and save harmless the City of Baltimore and its Department of Housing and Community Development; and the State of Maryland and its Department of Housing and Community Development, from any and all losses, claims or damages of every nature or description arising out of or in connection with this contract.I (we) authorize the staff of Neighborhood Housing Services of Baltimore, Inc., to obtain specific reports and verifications such as personal credit reports, income and asset information, etc. from any organization or entity that may be involved during the counseling process.I (we) understand that Neighborhood Housing Services of Baltimore, Inc. provides financial capability counseling/coaching after which I will receive a written action plan consisting of recommendations for handling my finances, possibly including referrals and other agencies as appropriate. I (we) understand that Neighborhood Housing Services of Baltimore, Inc. submits client-level information relating to the Project Reinvest: Financial Capability grant to the NeighborWorks America Data Collection System (DCS), opens files to be reviewed for program monitoring and compliance purposes, and conducts follow-up with clients related to program evaluation. I (we) I understand that I may opt-out of this requirement, but proof of this opt-out must be recorded in my client file.I (we) give permission for Project Reinvest: Financial Capability program administrators and/or their agents to follow-up with me within the next three years for the purposes of program evaluation. I (we) acknowledge that I have received a copy of Neighborhood Housing Services of Baltimore, Inc. Privacy Policy.I (we) understand that a photocopy of this form will serve as authorization.Dated this:______________________Month, Day, Year_________________________________Signature___________________________Print Name________________________Social Security Number_________________________________Signature___________________________Printed Name________________________Social Security NumberCREDIT REPORT AUTHORIZATION (BORROWER)Borrower:_____________________________________________________________________________First, Middle, LastCo-Borrower:_____________________________________________________________________________First, Middle, LastAddress:_____________________________________________________________________________Street_____________________________________________________________________________City, State, ZipBorrower Social Security Number: __________________________Co-Borrower Social Security Number (if both named on mortgage): ______________________________Borrower Date of Birth: ______________________________Co-Borrower Date of Birth: _______________________________I (We) hereby give permission to pull my (our) credit report for the purposes of my (our) application for assistance in regards to my (our) home or my (our) mortgage loan.Both Signatures are required if joint report is requested:________________________________Signature_____________Date___________________________________Print Name________________________________Signature_____________Date___________________________________Print NamePRIVACY POLICY AND PRACTICES OF NEIGHBORHOOD HOUSING SERVICES OF BALTIMORE, INCWe at Neighborhood Housing Services of Baltimore, Inc., value your trust and are committed to the responsible management, use and protection of personal information. This notice describes our policy regarding the collection and disclosure of personal information.Personal information, as used in this notice, means information that identifies an individual personally and is not otherwise publicly available information. It includes personal financial information such as credit history, income, employment history, financial assets, bank account information and financial debts. It also includes your social security number and other information that you have provided us on any applications or forms that you have RMATION WE COLLECTWe collect personal information to support our lending operations, financial counseling and to aid you in shopping for and obtaining a home mortgage from a conventional lender. We collect personal information about you from the following sources:Information that we receive from you on applications or other rmation about your transactions with us, our affiliates or rmation we receive from a consumer reporting rmation that we receive from personal and employment RMATION WE DISCLOSEWe may disclose the following kinds of personal information about you:Information we receive from you on applications or other forms, such as your name, address, social security number employer, occupation, assets, debts and rmation about your transactions with us, our affiliates or others, such as your account balance, payment history and parties to your rmation we receive from a consumer reporting agency, such as your credit bureau reports, your credit history and your creditworthiness.TO WHOM DO WE DISCLOSEWe may disclose your personal information to the following types of unaffiliated third parties:Financial service providers, such as companies engaged in providing home mortgage or home equity loan.Others, such as nonprofit organizations involved in community development, but only for program review, auditing, research and oversight purposes.YOU MAY OPT OUT OF CERTAIN DISCLOSURESYou 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.You may opt-out of this requirement, but proof of your decision to opt-out must be recorded in your client file.CONFIDENTIALITY AND SECURITYWe restrict access to personal information about you to those of our employees who need to know that information to provide products and services to you and to help them do their jobs, including underwriting and servicing of loans, making loan decisions, aiding you in obtaining loans from others, and financial counseling. We maintain physical and electronic security procedures to safeguard the confidentiality and integrity of personal information in our possession and to guard against unauthorized access. We use locked files, user authentication and detection software to protect your information. Our safeguards comply with federal regulations to guard your personal information.IF YOU WANT MORE INFORMATIONPlease contact us at 410-327-1200 or write to us at 25 E. 20th Street, Suite 170, Baltimore Maryland 21218By signing below, I hereby affirm that I have received the Privacy Policy for Neighborhood Housing Services of Baltimore, Inc. (NHSB).________________________________Signature_____________Date___________________________________Print Name________________________________Signature_____________Date___________________________________Print NameGENERAL CONFLICT OF INTEREST POLICYAPPLICATION OF POLICYThis policy applies to board members, employees, relatives of employees, and certain volunteers of Neighborhood Housing Services of Baltimore, Inc. (NHS), hereafter referred to as Staff. A volunteer is covered under this policy if that person has been granted significant independent decision making authority with respect to financial or other resources of the organization. Clients of NHS are here in after referred to as “interested parties.”DETERMINING A CONFLICT OF INTERESTA conflict of interest may exist when the interests or concerns of Staff may be seen as competing with the interests or concerns of an Interested Party. There are a variety of situations, which raise conflict of interest concerns including, but not limited to, the following:FINANCIAL INTERESTSA conflict may exist where Staff directly or indirectly benefits or profits as a result of a decision or transaction entered into with an Interested Party. Examples include situations were:Staff contracts to purchase or lease goods, services, or property from an Interested Party.Staff purchases an ownership interest in or invest in property owned by an Interested Party.Staff is provided with a gift, gratuity or favor of a substantial nature from a person or business entity for referring an Interested Party to that person or business entity.OTHER INTERESTSA conflict may also exist where Staff obtains a non-financial benefit or advantage that they would not have obtained absent their relationship with an Interested Party. Examples include:Staff seeks to make use of confidential information obtained from an Interested Party for their own benefit or for the benefit of a relative, business associate, or other organization.Staff seeks to take advantage of an opportunity which they have reason to believe would be of interest to an Interested Party.DISCLOSURE OF ACTUAL OR POTENTIAL CONFLICTS OF INTERESTStaff is under a continuing obligation to disclose any actual or potential conflict of interest as soon as it is known or reasonably should be known.Staff shall complete a disclosure statement at such time as an actual or potential conflict arises and shall be provided to the Chief Executive Officer of the organization.For board members, the disclosure statement shall be provided to the President (Chairman) of the Board. The President’s (Chairman’s) disclosure statement shall be provided to the Secretary of the Board. Copies shall also be provided to the Chief Executive Officer of the organization.In the case of volunteers with significant decision making authority, the disclosure statements shall be provided to the Chief Executive Officer of the organization. The Chief Executive Officer’s disclosure statement shall be provided to the President (Chairman) of the board.The Secretary of the Board shall file copies of all disclosure statements with the official corporate records of the organization.Interested parties who believe that a conflict of interest may or does exist as a result of Staff's interaction with said interested party, may file a formal written complaint with the Chief Executive Officer of NHS.Whenever there is reason to believe that an actual or potential conflict of interest exists between Staff of NHS and an interested party, the board of directors shall determine the appropriate organizational response. This shall include, but not necessarily be limited to, invoking the procedures described below, with respect to a specific proposed action or transaction.PROCEDURES FOR ADDRESSING CONFLICTS OF INTEREST – SPECIFIC TRANSACTIONSWhere an actual or potential conflict exists between Staff of NHS and an interested party with respect to a specific proposed action or transaction, Staff shall refrain from the proposed action or transaction until such times as the proposed action or transaction has been approved by the disinterested members of the board of directors of the organization. The following procedures shall apply:Staff who has an actual or potential conflict of interest with respect to a proposed action or transaction of the corporation shall not participate in any way in or be present during the deliberations and decision making of the organization with respect to such action or transaction. Staff me, upon request, be available to answer questions or provide material factual information about the proposed action or transaction.The disinterested members of the board of directors may approve the proposed action or transaction upon finding that it in the best interests of the corporation. The board shall consider whether the terms of the proposed transaction are fair and reasonable to the organization and whether it would be possible, with reasonable effort, to find a more advantageous arrangement with an entity that is not an interested party.Approval by the disinterested members of the board of directors shall be by vote or a majority of directors in attendance at a meeting at which a quorum is present. An interested party shall not be counted for purposed of determining whether a quorum is present, or for purposes of determining what constitutes a majority vote of directors in attendance.The minutes of the meeting shall reflect that the conflict disclosure was made, the vote taken and, where applicable, the abstention from voting and participation by the interested party.VIOLATIONS OF CONFLICT OF INTEREST POLICYIf the board of directors has reason to believe that Staff has failed to disclose an actual or potential conflict of interest, it shall inform the person of the basis for such belief and take the appropriate PLAINT PROCESSClients of Neighborhood Housing Services of Baltimore, Inc. (NHS), from time to time, may not be completely satisfied with the level of service provided and may wish to file a formal complaint. If the nature of the complaint deals with the services provided by a third party, such as a lender or contractor, then the complaint should be submitted directly to the appropriate party with a copy to NHS. While we are not able to exert influence over third party providers, we are always striving to work with only those businesses that provide the highest quality of service to our clients. Lender complaints can be filed with the Commissioner of Consumer Credit while contractor complaints will be governed by the “Arbitration” clause of the Contract entered into between the contractor and the client.If your complaint deals specifically with NHS, the following steps must be taken:You must provide, in writing, a complete explanation outlining the nature of the complaint including any NHS employees involved. You must provide a phone number where you may be reached during the day should additional questions be necessary.The written complaint must be delivered, either via mail or in person, to the attention of the Chief Operating Officer of Neighborhood Housing Services of Baltimore at 25 E 20th Street, Suite 170, Baltimore, MD 21218.Upon receipt of your complaint, the Chief Operating Officer will investigate and respond in writing within ten (10) days.If your complaint is not resolved to your satisfaction you may request a review by the Executive Director of NHS. The request for the Executive Director’s review must also be made in writing and delivered to the address listed above.Upon receipt of the request, the Executive Director will review the complaint and issue a written response within ten (10) days. The decision of the Executive Director shall be viewed as final.DISCLOSURE STATEMENT OF CONFLICT OF INTEREST POLICY AND COMPLAINT PROCESSBy signing below, I hereby affirm that I have received the Conflict of Interest Policy for staff, clients and volunteers of Neighborhood Housing Services of Baltimore, Inc. (NHSB).I have also been advised that NHSB’s activities include the purchase, rental, sales and rehabilitation of properties, and that I, as a client, are under no obligation to sell to, purchase or rent from, or use the rehabilitation services of NHSB. I further understand that NHSB, Inc. is a charitable organization and that in order to maintain its federal tax exemption it must engage primarily in activities which accomplish one or more of its tax exempt purposes.Further, I’ve been provided a copy of NHSB’s Client Complaint process and understand the steps I must take to submit a complaint.______________________________________________Print Name________________Date______________________________________________Client Signature______________________________________________Print Name________________Date______________________________________________Client SignatureDISCLOSURE OF INFORMATION ON LEAD BASED PAINT AND/OR LEAD BASED PAINT HAZARDSLead Warning StatementHousing built before 1978 may contain lead based paint. Lead from paint, paint chips, and dust can pose health hazards if not managed properly. Lead poisoning in young children may produce permanent neurological damage, including learning disabilities, reduced intelligence quotient, behavioral problems, and impaired memory. Lead poisoning also poses a particular risk to pregnant women. Potential homebuyers should be aware that homes built prior to 1978 might contain lead and take appropriate measures to educate themselves on the dangers of lead poisoning prior to completing a sale on a home. The seller of any interest in residential real property is required to provide the buyer with any information on lead based paint hazards from risk assessments or inspections in the seller’s possession and notify the buyer of any known lead based paint hazards. A risk assessment or inspection for possible lead based paint hazards is recommended prior to purchase.The “Protect your family from Lead in your Home” is being provided to prospective homebuyers to make certain they are aware of the dangers of lead in homes built prior to 1978.This is to certify that a copy of the “Protect your family from Lead in your Home” pamphlet has been provided to: ____________________________________________________________________________________Housing Counseling Agency: __________________________________________________________________________________________________Name of Authorized Person__________________________________Signature_______________DateThis is to certify that I have received a copy of the “Protect your family from Lead in your Home” pamphlet from: ____________________________________________________________________________________________________________________Name of Participant__________________________________Signature_______________Date__________________________________Name of Participant__________________________________Signature_______________DateHCA RESOURCES REFERRAL – HOMEOWNERSHIP COUNSELING AGENCIESBaltimoreOffice of Homeownership417 E Fayette Street, Suite 1125Baltimore, MD 21202Phone 410-396-3124 | Harbel Housing Partnership5807 Harford RoadBaltimore, MD 21214Phone 410-444-1400Fax 410-444-9181Baltimore Urban League512 Orchard StreetBaltimore, MD 21201Phone 410-523-8150 | Fax 410-523-4022Making Choices for Independent Living3011 Montebello TerraceBaltimore, MD 21214Phone 410-444-1400 | Fax 410-444-0825Belair Edison Housing Services3412 Belair RoadBaltimore, MD 21213Phone 410-485-8422 | Fax 410-485-0728NHS of Baltimore25 E 20th Street, Suite 170Baltimore, MD 21218Phone 410-327-1200 | Centro De La Comunidad3021 Eastern AvenueBaltimore, MD 21224Phone 410-675-8906 | Fax 410-675-3146Oliver Economic Development Corporation1400 E Federal StreetBaltimore, MD 21217Phone 410-685-0330 | denise.kelly@Comprehensive Housing Assistance, Inc.5721 Park Heights AvenueBaltimore, MD 21215Phone 410-466-1990 x211 | Fax 410-466-1996Reservoir Hill Improvement Council2001 Park AvenueBaltimore, MD 21217Phone 410-225-7547 | Fax 410-225-7455Development Corporation of NW Baltimore3521 W Belvedere AvenueBaltimore, MD 21215Phone 410-578-7190 | Fax 410-578-7193Southeast CDC3700 Eastern AvenueBaltimore, MD 21224Phone 410-342-3234| Fax 410-342-1719Druid Heights CDC2140 McCulloh StreetBaltimore, MD 21217Phone 410-523-1350 | Fax 410-523-1374St. Ambrose Housing Aid Center321 E 25th StreetBaltimore, MD 21218Phone 410-366-8550 | Garwyn Oaks Housing Resource Center2300 Garrison Boulevard, Suite 211Baltimore, MD 21216Phone 410-947-0084 | Fax 410-542-9055ReferralsDate: _____________________________Name(s): ______________________________________________Contact info.: ____________________________________________How Did You Hear About Us? Please mark with (?) and elaborate as neededNHS Outreach ____NHS Website _____Advertisement ____Realtor _____ Which Agency? ________________________Lender _____ Which Agency? _________________________Client Referral _____Baltimore City Government _____Baltimore County Government _____Black Women Build ____State of Maryland _____O’Hara Development ____Other Counseling Agency _____Bank of America _____MECU _____NeighborWorks _____ReBuild Metro ____Other _____ What? _________________________Release FormFor good and valuable consideration, the receipt of which is hereby acknowledged, I do hereby give permission to Neighborhood Housing Services of Baltimore, its agents, and others working under its authority (“Released Parties”), full and free right to use any video or digital recordings, photographs, digital images, drawings, renderings, voice recordings, sounds, audio clips and/or written descriptions containing my image/likeness (“images”), or verbal or written statements/quotes that I have made (“Testimonials”), and the right to use the Images and/or Testimonials, including reproductions, composites or alternations of the Images/Testimonials or likenesses based on the Images, in any manner, in connection with the advertising, business development, promotion, marketing, public relations and packaging for any product or service of the Released Parties, in any or all means of media, and the right to copyright the images and/or Testimonials. I waive all right of inspection and approval, and release the Released Parties, from any and all liability arising out of the exercise of the rights hereby granted.I agree that I have no rights to the Images and/or Testimonials and that all rights to the Images and Testimonials belong to the Released Parties. I agree that any Testimonials made by me are my own opinion and not that of Released Parties. I agree that I have no right to any additional consideration, compensation or accounting, and that I will make no further claim therefore for any reason. I agree that this Release is binding of my heirs, assigns and any other person claiming an interest in the Images.I do further certify that I am either of legal age, or possess full legal capacity to execute the foregoing authorization and release.Print Name: ___________________________________________________ Signature: ___________________________________________________? Check box if submitting electronicallyDate: ____________________________________________________Address: ____________________________________________________If the individual names above is under 18:I, ____________________, am the parent/legal guardian of the individual named above. I have read this release and approve of its terms.Print Name: _________________________________________________Signature: ___________________________________________________? Check box if submitting electronicallyDate: ___________________________________________________ _ Address: ____________________________________________________ 1050446487CFPB FINANCIAL WELL-BEING SCALE QuestionnaireNAME OR NUMBER6007608889516Part 1: How well does this statement describe you or your situation?This statement describes me Completely Very well Somewhat Very little Not at all. 1I could handle a major unexpected expense . 2I am securing my financial future . 3Because of my money situation, I feel like I will never have the things I want in life 4. I can enjoy life because of the way I’m managing my money . 5I am just getting by financially . 6I am concerned that the money I have or will save won’t last This statement describes me Completely Very well Somewhat Very little Not at all. 1I could handle a major unexpected expense . 2I am securing my financial future . 3Because of my money situation, I feel like I will never have the things I want in life 4. I can enjoy life because of the way I’m managing my money . 5I am just getting by financially . 6I am concerned that the money I have or will save won’t last Part 2: How often does this statement apply to you?This statement applies to me Always Often Sometimes Rarely Never7. Giving a gift for a wedding, birthday or other occasion would put a strain on my finances for the month . 8I have money left over at the end of the month 9. I am behind with my finances 10. My finances control my life This statement applies to me Always Often Sometimes Rarely Never7. Giving a gift for a wedding, birthday or other occasion would put a strain on my finances for the month . 8I have money left over at the end of the month 9. I am behind with my finances 10. My finances control my life Part 3: Tell us about yourself.11. How old are you? 18-61 62+ 12. How did you take the questionnaire? I read the questions Someone read the questions to me11. How old are you? 18-61 62+ 12. How did you take the questionnaire? I read the questions Someone read the questions to me ................
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