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Habitat for Humanity of Michigan Financial Coaching Intake Form

Part 1 : Intake Form

Applicant Name *
Applicant Name
Date
Date
Co-Applicant Name *
Co-Applicant Name
Address *
Address
Phone Number *
Phone Number
Other Contact Number
Other Contact Number
Household Information
Household Member 1 (Head of Household) *
Household Member 1 (Head of Household)
Household Member 1 Date of Birth *
Household Member 1 Date of Birth
Household Member 2 (Co-Head of Household) *
Household Member 2 (Co-Head of Household)
Household Member 2 Date of Birth *
Household Member 2 Date of Birth
Household Member 3
Household Member 3
Household Member 3 Date of Birth
Household Member 3 Date of Birth
Household Member 4
Household Member 4
Household Member 4 Date of Birth
Household Member 4 Date of Birth
Please add additional household members in this area. Additionally, please make sure to include their Name, Date of Birth, Social Security Number, Gender, and if they are Hispanic.
rental information
Current income sources
Employment
Employer Phone Number *
Employer Phone Number
Education
For statistical purposes only.
Applicant Name *
Applicant Name
This will be used as the electronic signature.
Co-Applicant Name *
Co-Applicant Name
This will be used as the electronic signature.
Todays Date *
Todays Date
Authorization & Release
I understand that by electronically signing this consent form, I am authorizing Habitat for Humanity of Michigan (HFHM), its agents, employee or Habitat Affiliates to request income and asset information from all income providers (ie, Social Security Administration, Employers, DHHS, etc), those entities listed on your intake form and any other related application forms (ie, local Habitat Affiliate application form, etc). Information may also be gathered from current or previous landlords if you are pursuing home ownership with Habitat. We may also receive information from credit reporting agencies, collection agencies and personal references for the purpose of program qualification and assistance. Further, you are allowing Habitat for Humanity of Michigan to provide this information to its agents, employees, or Affiliates involved with the Financial Coaching Network for the purposes in this program. The agents, employees, or Affiliates involved with HFHM Financial Coaching Network may also provide information to HFHM. We will also collect your information and outcomes of your efforts to provide to funders who support this program. Private companies (collection companies, etc) may not receive your personal information authorized by this form unless disclosure of such information is required under State or Federal Law. Confidentiality is important to us and we will always protect your privacy. *
I understand that by electronically signing this consent form, I am authorizing Habitat for Humanity of Michigan (HFHM), its agents, employee or Habitat Affiliates to request income and asset information from all income providers (ie, Social Security Administration, Employers, DHHS, etc), those entities listed on your intake form and any other related application forms (ie, local Habitat Affiliate application form, etc). Information may also be gathered from current or previous landlords if you are pursuing home ownership with Habitat. We may also receive information from credit reporting agencies, collection agencies and personal references for the purpose of program qualification and assistance. Further, you are allowing Habitat for Humanity of Michigan to provide this information to its agents, employees, or Affiliates involved with the Financial Coaching Network for the purposes in this program. The agents, employees, or Affiliates involved with HFHM Financial Coaching Network may also provide information to HFHM. We will also collect your information and outcomes of your efforts to provide to funders who support this program. Private companies (collection companies, etc) may not receive your personal information authorized by this form unless disclosure of such information is required under State or Federal Law. Confidentiality is important to us and we will always protect your privacy.
Applicant's Electronic Signature
Co-Applicant's Electronic Signature *
Co-Applicant's Electronic Signature
Today's Date *
Today's Date
Part 2: Monthly household budget
Net (after Taxes) Income
$
$
$
$
$
$
Fixed Expenses
$
$
$
$
$
$
$
$
$
$
$
Flexible Expenses
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Please add amounts from the Flexible Expenses Section.
Occasional Expenses
$
$
$
$
$
$
$
$
$
Please add amounts from the Occasional Expenses Section.
$
Debt Reducing Expenses
Please list all Debt Reducing items and their amount.
$
Final calculations
$
$
$
Signatures
Applicant Name *
Applicant Name
This will serve as your Electronic Signature
Co-Applicant Name *
Co-Applicant Name
This will serve as your Electronic Signature.