We collect demographic information due to financing and program requirements. Please refer to the disclosures for more information.

Do you or anyone in your household:

*Please provide 1 month documentation or benefit letter for each question that you answered "yes" to.

PROGRAM DISCLOSURE

NeighborImpact and Program Purposes: NeighborImpact is a nonprofit, HUD approved comprehensive community action agency. The HomeSource Department offers counseling, coaching, and education on credit/budget management, financial capability, asset building, pre-purchase, reverse mortgages, loss mitigation, individual development accounts, homebuyer education/counseling, post-purchase, and financial literacy. NeighborImpact Weatherization program offers home rehabilitation services, NeighborImpact Lending department offers a series of loan products including down payment assistance, preservation loans, and small business loans. We serve all clients regardless of income, race, color, religion/creed, sex, national origin, age, family status, disability, or sexual orientation/gender identity. We administer our programs in conformity with local, state, and federal anti-discrimination laws, including the federal Fair Housing Act (42 USC 3600, et seq.). As a program participant, please affirm your roles and responsibilities along with the following disclosures. Sign and date the form on the following page.

 

Agency Conduct: No NeighborImpact employee, officer, director, contractor, volunteer, or agent shall undertake any action that might result in, or create the appearance of, administering counseling operations for personal or private gain, provide preferential treatment for any person or organization, or engage in conduct that will compromise our agency’s compliance with federal regulations and our commitment to serving the best interests of our clients.

 

Agency Relationships: NeighborImpact has financial affiliations with HUD, OHCS, NeighborWorks America, E-Home America, and Framework. NeighborImpact also has received donations from Umpqua Bank,  JP  Morgan  Chase  &  Co,  Bank  of  America  Charitable  Foundation  Inc.,  Washington  Federal  Foundation,   Wells   Fargo   Foundation, Brooks Resources Corporation, Central Oregon Association of Realtors, Oregon Association of Realtors Home Foundation, Hayden Homes, Rooted Homes, First Story and Neighborhood Partnerships. As a program participant, you are not obligated to use the products and services of NeighborImpact or our industry partners.

 

Alternative Services, Programs, and Products & Client Freedom of Choice: NeighborImpact lending department offers first- time homebuyer down payment assistance. However, you are not obligated to participate in this or other NeighborImpact programs and services while you are receiving housing and/or financial counseling from our agency. You may consider seeking alternative products and services, including those offered by the Federal Housing Administration (FHA), Oregon State first-time homebuyer loan programs, and/or United States Department of Agriculture (USDA) loans. A list of community resources is provided during your initial session and/or available anytime with our receptionist. You are entitled to choose any real estate professionals, lenders, and lending products that best meet your needs.

Referrals and Community Resources: You will be provided a community resource list which outlines many county and regional services available to meet a variety of needs related to your housing and financial goals. You may also be referred to other services of the organization or other agencies that may be able to assist you with particular concerns that have been identified. The Community Resources identifies alternative agencies that provide services, programs or products equivalent to those offered by NeighborImpact and its industry partners. You understand that you are not obligated to use any of the services offered to you.

Communications: By providing your personal contact information, you agree to receive communications from NeighborImpact related to the service, including industry news and information and/or programs of interest  or  marketing material. You may unsubscribe from these at any time.

Privacy Policy: I/we acknowledge that I/we received a copy of NeighborImpact’s Privacy Policy.

Errors and Omissions and Disclaimer of Liability: I/we agree NeighborImpact, its employees, agents, and directors are not liable for any claims and causes of action arising from errors or omissions by such parties, or related to my participation in NeighborImpact counseling; and I hereby release and waive all claims of action against NeighborImpact and its affiliates. I have read this document, understand that I have given up substantial rights by signing it, and have signed it freely and without any inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law. If any provision of this document is unenforceable, it shall be modified to the extent necessary to make the provision valid and binding, and the remainder of this document shall remain enforceable to the full extent allowed by law.

Quality Assurance: In order to assess client satisfaction, program evaluation, and in compliance with grant funding requirements, NeighborImpact, or one of its partners, may contact you during or after the completion of your housing counseling and/or financial capability services. You may be asked to complete surveys asking you to evaluate your client experience. Your survey data may be confidentially shared with NeighborImpact grantors such as HUD, OHCS, NeighborWorks America and/or Neighborhood Partnerships.

 

Homeowner Disclaimer: I understand and agree that no warranties, expressed, or implied, are made by NeighborImpact or its employees to the homeowner for materials furnished or work performed pursuant to this agreement. I agree to release and hold harmless NeighborImpact and its staff from all liability arising out of the performance of said improvements/evaluations. I grant permission to the NeighborImpact Weatherization Program enter and evaluate the Energy Score of my/our dwellings for the purpose evaluating the energy usage and will take into consideration any advice stated by the evaluator.

 

I/we certify that the information provided in this application is true and correct as of the date set forth below, and acknowledge my/our understanding that intentional or negligent misrepresentation(s) of the information contained in this application may result in civil liability and/or criminal penalties including, but not limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Section 1001, et seq. And liability for monetary damages to the Lender, its agents, successors and assigns, insurers and any other person who may suffer any loss due to reliance upon any misrepresentation which I/we have made on this application. 

 

I acknowledge that I received, reviewed and agree to NeighborImpact’s Program Disclosures

 

NEIGHBORIMPACT PRIVACY POLICY

NeighborImpact (NI) is committed to assuring the privacy of individuals and/or families who have contacted us for assistance. We realize that the concerns you bring to us are highly personal in nature. We assure you that all personal information shared both orally and/or in writing will be managed within legal and ethical considerations. Please carefully review this notice as it describes our policy regarding the collection and disclosure of your nonpublic, personal information. Your “nonpublic personal information” (information that identifies you personally and that is not otherwise publicly available information) such as your total debt information, income, living expenses, and personal information concerning your financial circumstances, will be provided to creditors, program monitors, and others only with your authorization and signature. We may also use anonymous aggregated case file information for the purpose of evaluating our services, gathering valuable research information, and designing future programs. NeighborImpact has a client complaint policy. You can request a copy of it at any time from our agency or you can download it from our website www.neighborimpact.org

 

TYPES OF PERSONAL INFORMATION WE GATHER ABOUT YOU
1. Information we receive from you orally, or on application or other forms, such as your name, address, social security number, assets, and income.
2. Information about your transactions with us, your creditors, or others, such as your account balance, payment history, transactions and credit card usage; and
3. Information we receive from a credit reporting agency, such as your credit history and credit reports.
4. Within the organization, we restrict access to nonpublic personal information about you to those employees who need to know that information to provide services to you. We maintain physical, electronic and procedural safeguards that comply with federal regulations to guard your nonpublic personal information.

 

YOU MAY OPT-OUT OF CERTAIN DISCLOSURES
5. You 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.
6. If you choose to “opt-out”, we will not be able to answer questions from your creditors or meet program compliance. If you choose to opt out, DO NOT SIGN UNDER THE RELEASE CLAUSE BELOW. You may change your “opt-out” decision at any time by contacting our agency.
1. If you choose to allow us to release your information as provided in this Privacy Policy, sign under the “RELEASE” clause below. If you later change your decision and wish to “opt-out” going forward, you must notify NeighborImpact in writing at homesource@neighborimpact.org. The opt-out will not apply to actions already taken based upon your prior consent.

 

RELEASE OF INFORMATION TO THIRD PARTIES
1. You understand and agree that NeighborImpact may disclose some or all of the personal information collected, as described above, to third parties that it determines would be helpful to you or will assist with your counseling needs. Examples of such entities including creditors, financial service providers, federal, state, local public agencies, non-profit partners, and/or any other pre-authorized individuals or organizations.
2. You understand and agree that NeighborImpact submits client level information to meet grant requirements, opens files to be reviewed for program monitoring and compliance purposes and may provide communication exchanges, such
as, but not limited to emails to agencies that support the operations and mission of NeighborImpact, including HUD, City of Bend, OHCS, HSCP, NeighborWorks America and NeighborWorks Umpqua, other grant administrators, funders and private foundations.
3. You give permission to grant administrators and/or their agents to contact you as needed within the next three years for program evaluation.
4. You understand that NeighborImpact may also disclose any nonpublic personal information to anyone as permitted by law (e.g., if NI are compelled by legal process).

RELEASE: I hereby authorize NeighborImpact to release nonpublic personal information as stated above. I acknowledge that I received a copy of NeighborImpact’s Privacy Policy, and that I have read and understood NeighborImpact’s privacy practices and disclosures. I acknowledge that a copy or electronic reproduction of this form is as valid as the original.

NeighborImpact Authorization to Obtain and Release Information

 

I hereby authorize the release/exchange of my information to and from NeighborImpact in order to assist with my case.

 

I understand and agree that no warranties, expressed or implied are made by NeighborImpact or its employees to the homeowner for materials furnished or work performed. Pursuant to this agreement, I agree to release and hold harmless NeighborImpact and its staff from all liability arising out of the performance of said improvements.

 

I give permission for NeighborImpact to request from the utility billing history and energy usage, which is used in evaluating the energy conservation effectiveness of work proposed and performed further direct my utility and/or fuel companies to make such records available to NeighborImpact. I understand that no information obtained through these releases shall be made public in such a manner that the dwelling or occupants can be identified.

 

This consent is voluntary and shall remain in effect until is revoked or NeighborImpact's services are complete. I further acknowledge that I may revoke this consent in writing at any time except to the extent that action based on this consent has already been taken.

 

I acknowledge that a copy or electronic reproduction of this form is as valid as the original.

HomeSource of NeighborImpact is a HUD-approved housing counseling agency serving Crook, Deschutes Jefferson Counties and the Confederated Tribes of Warm Springs.