Intake Form Home Intake Form Intake Form Name First Last What county do you currently live in?* Physical Address* Street Address Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia 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 Armed Forces Americas Armed Forces Europe Armed Forces Pacific State ZIP Code Phone Email Enter Email Confirm Email What type of programs or services are you interested in?* Home Purchase Mortgage Assistance Seeking Shelter or Homeless Services Rental Topics Homeowner Services Financial Management, Education & Credit Coaching Reverse Mortgage Counseling Preparedness Planning & Financial Recovery Counseling Other Date of Birth* Marital Status Married Single Choose Not to Respond Highest Education Level College Graduate School Junior College High School/GED Junior High School Vocational None Other Active Military? Yes No Not Available Military Veteran? Yes No Not Available Are you disabled or disabled dependent? Yes No What is your race? American Indian/Alaskan Native Asian Black/African-American Native Hawaiian or Other Pacific Islander White American Indian or Alaskan Native and White Asian and White Black or African-American and White American Indian or Alaskan Native and Black or African-American Other multiple race Choose not to respond What is your ethnicity? Indicates if you are Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Hispanic Not Hispanic Choose not to respond Gender Male Female What is your English proficiency level? Household is Limited English Proficient Household is not Limited English Proficient Choose not to respond Are you a first-time homebuyer? Yes No Not applicable What is the size of your household? The number of people currently residing in your household (e.g. the number of people living in the house at the time service was provided). Please enter a number from 0 to 50. What is your annual family or household income? The household gross (pre-tax) income during the year as reflected in your loan or grant application. Please enter a number from 0 to 500000. Privacy Notice Opt-out? Yes No Is there any other information you would like to provide? Attachments Drop files here or © 2017 First Home Alliance, Inc. - All Rights Reserved | Designed by Peerless Tech Solutions