Housing Counseling Intake Form

The Housing and Redevelopment Authority of Cumberland County (CCHRA), in partnership with the Pennsylvania Housing Finance Agency (PHFA), provides Housing Counseling services and workshops free of charge to our local community. Our mission is to expand homeownership opportunities for low and moderate-income residents throughout the county through homebuyer education and counseling services.

To better understand the populations we serve, we require that each participant complete the following questionnaire. The information you provide here will be used to identify and understand the demographic population we serve and to assist you in your homeownership goals.

Your responses will help us continue to provide free services for others in the future. We thank you for taking the time to complete this form in its entirety.

"*" indicates required fields

Personal Information

Client Name*

Client Address*

Street Address Address Line 2 City State ZIP Code

Client Phone*

Client Email*

Telephone Type*

Best time to call?*

Morning

Afternoon

Evening

Date of Birth*

Client Marital Status*

Household Type*

Client Gender*

Client Citizenship Status*

Client immigration status?*

Client Military status*

Client Disability?*

Client's highest education level attained?*

Client Race*

Client Ethnicity*

English is client's second language?*

Is client English-proficient?*

Is client in need of translation services?*

Please be aware that we require 3 business days advance notice for any requested translation services for our workshops or counseling sessions.

Client's preferred language*

What is client's current living situation?*

Has client owned a home in the past three years?

Number of people in client's household*

Please enter a number from 0 to 100.

Number of children/dependents in client's household*

Please enter a number from 0 to 100.

Client's Goals*

Please select the goals that are most important to you now.

Please check the items you feel might be an obstacle in purchasing a home:*

Not enough money for downpayment / closing costs

Not enough income to afford mortgage payments

Housing prices too high

Do not like the type of housing available

Cannot decide which community to live in

Mortgage interest rates are too high

Credit problems

Too much debt

Other

Please let us know where you are in your home search:*

I am just getting started.

I have reached out to a lender/Realtor, but do not currently have pre-approval for a mortgage.

I have received pre-approval from a lender.

I’ve made an offer on a home and it has been accepted by the Seller.

Not sure

Goals or Questions

Please use this space to list any specific homeownership/financial goals you would like to address in counseling sessions. You may also use this space to list any questions you may have.

How did you hear about us?*

Website

Social Media

Lender

Real estate agent / broker

Friend / family member

Other organization or business

Other individual

Are you planning on purchasing a home with someone else?*

Co-Client's Personal Information

Co-Client Name (spouse, partner or other)*

First Last

Relationship to Client*

Co-Client Address

Enter the address of spouse, partner, or other individual (if different from client address)

Street Address Address Line 2 City State ZIP Code

Co-Client Phone*

Co-Client Email*

Co-Client Telephone Type*

Best time to call?*

Morning

Afternoon

Evening

Any

Co-Client Date of Birth*

Co-Client Marital Status*

Co-Client Gender*

Co-Client Citizenship Status*

Co-Client immigration status?*

Co-Client Military status*

Co-Client Disability?*

Co-client's highest education level attained?*

Co-Client Race*

Co-Client Ethnicity*

English is co-client's second language?*

Is co-client English-proficient?*

Is co-client in need of translation services?*

Please be aware that we require 3 business days advance notice for any requested translation services for our workshops or counseling sessions.

Co-client's preferred language*

What is co-client's current living situation?*

Has co-client owned a home in the past three years?

How close are you to a home purchase?*

0-3 months

4-6 months

7-12 months

1 year or more

Name of referring individual / organization:

Client Signature*

Co-Client Signature*

Housing Counseling Disclosures, Authorizations, and Agreements

Please review and sign each authorization, disclosure, and agreement below. If you have questions regarding services or program requirements, please contact our Housing Counselor.

Disclosure to Client for Housing Counseling Services*

The Housing and Redevelopment Authority of the County of Cumberland (CCHRA) offers free housing counseling services in areas such as credit and budgeting, pre-purchase, non-delinquency post-purchase, and default/delinquency. The agency also offers Pre-Purchase Homebuyer Education workshops which include information regarding Anti-Predatory Lending/Foreclosure Prevention, and Fair Housing/Fair Lending topics.

Credit and Budgeting: Clients receive help in understanding and improving their financial health. Counselors assist clients in understanding how to manage and develop good credit, analyze credit reports, improve credit scores, and help develop strategies to reduce debt. The counselor will also assist clients in creating a realistic spending plan, identifying areas of excess spending, developing ways to increase savings, and setting SMART financial goals.

Pre-Purchase: Clients receive one-on-one counseling which covers the entire homebuying process. Counselors will work with clients to evaluate their readiness to buy, improve credit, develop a budget, explore mortgage options, identify down payment assistance programs, and review important considerations such as hiring a licensed and reputable professional to perform a home inspection prior to closing. Clients will receive the knowledge and tools they need to make informed decisions and achieve sustainable homeownership.

Post-Purchase: Clients will receive support in maintaining successful, long-term homeownership. Counselors offer guidance on topics such as home maintenance, budgeting for home expenses, property taxes and insurance, reviewing loan or refinance options for home improvement projects, avoiding predatory lending, and planning for future financial needs.

Pre-Purchase Homebuyer Education Workshop: Attendees will receive information on topics such as homebuyer readiness, the homebuying process, credit and budgeting, mortgage options, working with real estate professionals, maintaining a home, managing home expenses, understanding fair housing laws, avoiding predatory loans, and foreclosure. Participants gain the knowledge and confidence needed to make informed decisions and navigate the path to successful homeownership.

Our agency has a financial relationship with the Pennsylvania Housing Finance Agency (PHFA), through whom we receive funding for Housing Counseling services. CCHRA also adheres to Housing and Urban Development (HUD) rules and regulations regarding housing counseling services. These organizations provide CCHRA with program oversight and guidance. In addition, we partner with many local organizations including realtors, lenders, and community service providers who provide educational information on standard industry practices at our workshops and may offer refreshments and information regarding their services to participants and attendees.

In addition to providing HUD-Certified Housing Counseling services, CCHRA also manages other Housing and Redevelopment programs, providing services which include Public Family Housing, Permanent Supportive Housing, the Family Self-Sufficiency Program, Rapid Rehousing Rental Assistance, and Section 8 Housing Choice Vouchers for Cumberland County. CCHRA also owns and manages multiple rental properties and offers grant assistance programs such as our Down Payment and Closing Cost Assistance Program. These programs utilize funding from HUD, the Community Development Block Grant (CDBG), along with other federal, state and local funds.

There is no obligation to receive, purchase, or use any product or service offered by this agency or any services of its industry partners or other party in exchange for your receiving HUD housing counseling services.

As a condition of our services, and in alignment with meeting our counseling goals, and in compliance with HUD’s Housing Counseling Program requirements, we may provide information on alternative services, programs, and products available to you, if applicable and known by our staff.

CCHRA and its housing counselors provide impartial, unbiased housing counseling services and do not steer clients to any specific lender, realtor, or service provider. CCHRA does not receive compensation, referral fees, or other benefits for recommending or selecting particular providers, and counselors are prohibited from offering services or participating in activities that could result in personal or financial benefit to themselves or their immediate family. While CCHRA may maintain partnerships or funding relationships with various community organizations, these affiliations do not influence the guidance provided to clients. Clients are encouraged to select the lender, realtor, or other service providers of their choice.

I/We have read and received a copy of the disclosure above.

Client Signature*

Co-Client Signature*

CCHRA Privacy Policy for Housing Counseling Programs*

Cumberland County Housing and Redevelopment Authorities (CCHRA) is a HUD-approved housing counseling agency committed to maintaining the confidentiality, integrity, and security of your personal information. We collect only what is necessary to provide housing counseling and education services, meet PHFA, HUD, and funder requirements, and support your housing goals. This policy explains how your information is collected, used, shared, and safeguarded in compliance with HUD and federal privacy laws.

Information We Collect & How It’s Used

CCHRA collects information you provide through intake forms, counseling sessions, or documents such as credit reports, pay stubs, or tax returns. This may include your name, contact details, date of birth, demographic data (for HUD/PHFA reporting), Social Security number (or last four digits), income, employment, household information, mortgage or rental data, and notes from counseling sessions.

Your information is used to:

Provide housing counseling, education, and financial capability services
Create an individualized action plan
Meet PHFA, HUD, and funder reporting requirements
Evaluate program outcomes and effectiveness
Obtain credit reports (with your consent)
Coordinate services or referrals with partners (with your consent)

Information Sharing & Disclosure

CCHRA does not sell or rent your personal information. We may share information only as required or permitted by law with:

PHFA, HUD, and HUD-approved intermediaries for reporting, monitoring, and compliance
Funders or partners under grant agreements
Credit bureaus (with written consent)
Service providers or lenders you authorize
Law enforcement or government agencies when legally required

As a HUD-approved agency, CCHRA must collect personal information for program delivery and reporting. HUD and its agents may access this data for compliance and evaluation and must protect it under the Privacy Act of 1974 (5 U.S.C. § 552a).

Record Retention, Security & Communication

Client records are retained for at least three (3) years after case closure or longer if required by funders, then securely destroyed. We safeguard your information through locked storage, password-protected databases, staff access limits, and secure file disposal.

We may contact you by phone, mail, email, or secure electronic means. Since regular email may not be encrypted, avoid sending sensitive data unless through a secure system provided by CCHRA. Policy updates will be posted online or available upon request.

Client Rights

You have the right to:

Review your file upon written request
Request corrections to inaccurate information
Withdraw consent for data sharing (except where required by law)
Your information will not be shared for marketing or solicitation purposes.

Client Consent & Acknowledgment

We will obtain your written authorization before sharing information with third parties for purposes not required by law or HUD/PHFA program regulations. You may withdraw consent by written request.

By signing this form, you verify and agree to the following:

I have received and reviewed CCHRA’s Housing Counseling Privacy Policy.
I understand how my personal information may be collected, used, and shared.
I understand my information may be shared with PHFA, HUD, HUD-approved intermediaries, or funders for compliance and evaluation.
I consent to the collection and use of my personal information as described.

I/We have read, understand, and agree to CCHRA’s Housing Counseling Privacy Policy, as stated above.

Client Signature*

Co-Client Signature*

Client Signature*

Co-Client Signature*

Client Social Security Number*

Please provide your full social security number. Credit reports are pulled prior to, or at the time of the initial appointment with the Housing Counselor. A credit report is required for the initial appointment. Reports may be pulled subsequently to track outcomes and data. For additional information or questions, please contact CCHRA’s Housing Counselor.

Co-Client Social Security Number*

Client Signature*

Co-Client Signature*

Client / Counselor Agreement*

Thank you for selecting CCHRA to support you throughout your home ownership journey. Our mission is to expand homeownership opportunities for low and moderate-income residents throughout the county through homebuyer education and counseling.

Please read the following client/counselor agreement carefully to understand how CCHRA will provide services, and what is expected.

Services
CCHRA and its counselor agrees to provide the following services:

Development of a household budget.
Analysis of credit report.
Presentation and explanation of reasonable options.
Use SMART goal setting techniques.
Provide education, resources, and tools to assist you in reaching your goals.
Services will be customized according to your specific situation and goals.
Services can include but are not limited to household expense reductions, savings planning, debt reduction, credit improvement, financial product and services education, assessment of family housing needs, determining eligibility for first-time homebuyer programs, affordability analysis, the role of credit in homebuying process, assistance in getting pre-qualified for a mortgage loan, information on routine home maintenance, energy efficiency, hiring/firing a contractor, housing code enforcement procedures, refinancing, home equity, rights and responsibilities of homeowners.
Develop an Action Plan after each session documenting what was done, next steps, and additional documents needed.

Time Commitment & Counseling Overview
Sessions are scheduled for one hour. In person sessions are recommended for the first appointment. Remote sessions may be offered if client is able to communicate through this format, and if authorized by PHFA/CCHRA. Credit reports are pulled at the time of the initial session, and subsequent sessions, as needed, and a copy is provided to the client.

Communication
At least once a month, the counselor and client will communicate to discuss progress on goals.

Termination/Reinstatement of Services
Services can be discontinued at any time by the client or counselor. Termination of services by the counselor will occur if there has been no contact with the client for a period of 90 days. Counselors can terminate services if client is not participating in the process or is hindering the process. Client can terminate services at any time either verbally or in writing. Services can be reinstated at any time. Any client whose case has been closed out for any reason will need to schedule a new client intake appointment.

Cancellation
Clients and counselors can cancel appointments at any time due to weather, conflicts, or other life events. Client and counselor will communicate cancellations 24 hours in advance unless otherwise unable or conflict/event is sudden.

Agreement
I agree to the following terms of service:

I will always provide honest and complete information to my/our counselor, whether verbally or written.
I will provide all necessary documentation and follow-up information within the time frame requested.
I will be on time for appointments and understand that if I am late for an appointment, the appointment will still end at the scheduled time.
I will call or email in advance of our appointment if I will be unable to attend.
I will contact the counselor about changes in my situation, and maintain communication.
I understand that breaking this agreement may cause CCHRA to terminate its counseling services and assistance to me.
I will adhere, to the best of my ability, to the client/counselor agreement.

I/We have read the Client/Counselor Agreement and will adhere to its terms of service as stated above.

Client Signature*

Co-Client Signature*

Are You Ready To Be a Homeowner? Self-Assessment Tool

Please complete PHFA’s Self-Assessment. This is to help us understand where you are in the homebuying process, so that we can provide you with the resources and services that fit your needs.

Readiness Statements

Please select whether you agree or disagree with each statement below.

Being in debt does not bother me.*

Agree

Disagree

The thought of having long-term debt is disturbing to me.*

Agree

Disagree

I enjoy working around the house and yard.*

Agree

Disagree

I would much rather shop, go out to eat, or read a book then spend any time around the house or yard.*

Agree

Disagree

I prefer finding a good job and staying with it*

Agree

Disagree

I prefer changing jobs from time to time, finding excitement in starting all over.*

Agree

Disagree

I prefer staying in one place and being committed to one community.*

Agree

Disagree

I do not like being limited to one community or location for a long period of time.*

Agree

Disagree

I am able to handle the financial responsibilities of mortgage payments now*

Agree

Disagree

I would be better off waiting until I can save more money or my financial situation improves.*

Agree

Disagree

Mortgage Qualifications and Other Considerations

Please answer the following questions to the best of your ability. If you are unsure of an answer, please type “unsure.”

Are you a first-time homebuyer?*

Yes

County of Interest (Where would you like to buy a home?)*

Purchase Price (Your target home price)*

Home of Interest*

Existing home

New home

Number of persons in household*

Number of children in household*

Are you disabled?

Yes

Are you living with persons who are disabled?

Yes

What is your credit score?*

How many years have you been employed?*

What is your yearly gross (before taxes & deductions) income?*

What is your monthly gross (before taxes & deductions) income?*

What is your monthly net (after taxes & deductions) income?*

Average overtime worked?*

Current monthly rent?*

Do you have a Section 8 voucher?*

Yes

Monthly Section 8 Voucher Income?*

What are your total current monthly expenses?*

Amount of cash reserves available?*

Amount of any Securities, Mutual Funds, Stocks?*

Do you owe or receive monthly child support?*

Yes, I owe child support.

Yes, I receive child support.

Amount of monthly child support payment?*

Is this court-ordered?*

Yes

Do you have any monthly social security, disability, or other public assistance income?*

Yes

Amount of monthly social security, disability, public assistance income? Please also indicate type.*

Required Documents

To help your housing counselor get a complete picture of your financial situation and provide the best possible guidance, please gather and provide copies of the following documents before your counseling session. (Please provide documents for all household members contributing to income or expenses.)

Client's Driver's License or ID*

Please provide a clear copy of your driver’s license, passport, or other government-issued photo ID.

Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.

Co-Client's Driver's License or ID*

Please provide a clear copy of your driver’s license, passport, or other government-issued photo ID.

Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.

PHFA's 3-in-1 Disclosure Form

Please complete and sign PHFA’s 3-in-1 Disclosure Form.(Areas requiring signatures/initials are highlighted.) Please note that you will need to download and save a copy of your completed form before attaching it below.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.

Types of Income Received*

Please check all sources of income received:

Employment (Provide pay stubs for all jobs)

Self-employment income (Provide 2 years tax returns & most recent profit & loss statement)

Social Security or SSI (Provide award letter)

Pension or retirement (Provide income statements)

Unemployment (Provide benefits letter)

Child support (Provide court order or payment history)

Alimony (Provide court order or payment history)

Public assistance (TANF, SNAP, etc.) (Provide benefit letter)

Other

Income Documents

Upload proof of income here. Please provide documentation for the most recent 30 days of each source of income checked above.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.

Bank and Asset Statements*

Please check if you have the following:

Checking Accounts

Savings Accounts

Investment accounts (stocks, bonds, mutual funds, etc.)

Retirement accounts (401(k), IRA, pension, etc.)

Cash app balances (if used regularly for deposits/expenses, e.g., Venmo, Cash App)

Other

Asset Documents

Upload account statements here. Please provide the most recent 30 days (or most recent monthly statement) for each account checked above. At minimum, we need proof of 1 asset (checking accounts showing income/expenses are often most useful).

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.

Debt and Credit Accounts*

Please check if you have the following:

Credit cards

Auto loans

Mortgage

Student loans

Personal loans

Buy Now, Pay Later (BNPL) loans (Affirm, Klarna, PayPal, Afterpay, etc.)

Collections or charge-off notices

Other

Debt and Credit Documentation

Upload account statements here. Please provide the most recent 30 days (or most recent monthly statement) for each account checked above.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.

Other Common Monthly Bills*

Please check if you have any of the following monthly bills:

Bills & Expense Documentation

Provide copies or a list of your regular monthly bills (bank statements showing expenses and payments made are acceptable). At minimum, we need proof of 1 bill/expense.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.