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Mortgage Intervention On-line Intake Form

                                     Free and Confidential


The Housing Council
Mortgage Intervention On-line Intake Form
(Prevention, Delinquency, Foreclosure, Predatory Lending)

      Personal Information

     1 First Name             Last Name         

        Phone Number       Work Number  


     2 First Name             Last Name      

        Phone Number       Work Number  

        How did you hear about our services? (Specify)

        Best time to contact you (Between 8:30am and 4:00pm)
              Perferred Method of Contract     Phone    Email

      Mailing Address

      Full Address      

      Email Address   

       Mortgage Information

       Is the mortgage and deed in your name?   Yes   No    If no, specify name

       Mortgage Company  

       Months Behind        Payment     Mortgage Type 

       Escrow Includes (Check all that apply) 
        
 
       2nd Mortgage or Home Equity?   Yes    No

       Reason for Delinquency or Consultation               
          

       Income Source Information (select all that apply)

        None   Employed   SSD  SSI   PA   Unemployment   Other (specify)