HomeSource Intake Form

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

Please list the type(s) debt you have. List total debt for each item instead of monthly payment.

NeighborImpact and Program Purposes: NeighborImpact (NI) is a nonprofit, HUD approved comprehensive community action agency. The HomeSource Department offers the following HUD counseling and education services: financial management/budget counseling (FBC), financial, budgeting and credit repair workshops (FBW), pre-purchase counseling (PPC), pre-purchase homebuyer education workshops (PPW), non-delinquency post purchase workshops/counseling (NDW), reverse mortgage counseling (RMC), mortgage delinquency and default resolution counseling (DFC), resolving/preventing mortgage delinquency (DFW).  HomeSource also offers asset building opportunities via individual development accounts (match savings program), serves as intake agency and/or liaison to the State of Oregon mortgage default and foreclosure prevention programs.

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.

One-on-One Services Client and Coach/ Counselor Roles and Responsibilities:

Coach/Counselor's Roles and Responsibilities

• Review your housing and/or financial goal and your finances; which include your income, debts, assets, and credit history

• Prepare a Client Action Plan that lists the steps that you and your counselor will take in order to achieve your goal

• Review household budget and discuss options to manage your debt, expenses, and savings according to your goals

• Provide referrals to other agencies/services as appropriate

   

• Your counselor is not responsible for achieving your housing or financial goal, but will provide guidance and education in support of your goal

• Neither your counselor nor NeighborImpact employees, agents, or directors may provide legal advice

Clinet's Roles and Responsibilities

• Complete the steps that you developed in conjunction with your counselor as stablished in your Client Action Plan

   

• Provide accurate information about your income, assets, debts, expenses, credit, and employment

   

• Attend appointments, return calls & emails, provide requested paperwork in a timely manner

   

• Notify your counselor when changing goals

   

• Attend educational workshop(s) (i.e. homebuyer education workshop) as recommended

   

• Complete surveys and program evaluations

   

• Retain an attorney if seeking legal advice and/or representation

Termination of Services: Failure to work cooperatively with your counselor and/or NeighborImpact will result in the discontinuation of counseling services. This includes, but is not limited to, missing three appointments.

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 and/or has received financial support from HUD, Oregon Housing and Community Services (OHCS), NeighborWorks America (NWA), Neighborhood Partnerships (NP), Community Services Block Grant (CSBG), E-Home America, Framework, RootedHomes, First Story, Thistle & Nest, Umpqua Bank, JP Morgan Chase & Co, Bank of America  Charitable  Foundation  Inc.,  Washington  Trust Bank,  Wells  Fargo  Foundation, Mann Mortgage, Brooks Resources Corporation, Central Oregon Association of Realtors, Oregon Association of Realtors Home Foundation and Hayden Homes. 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 HomeSource department offers Individual Development Accounts (IDA) match savings program, NeighborImpact lending department offers first- time homebuyer down payment assistance. However, you are not obligated to participate in these 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, NWA, NP, and/or other grantors.   

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

I/We understand that any intentional or negligent representation(s) of the information contained on this form may result in civil liability and/or criminal liability under the provisions of Title 18, United States Code, Section 1001.

 

NeighborImpact (NI) is committed to assuring the privacy of individuals and/or families who have contacted with us for assistance. We realize that the concerns you bring to us are highly personal. We assure you that all personal information shared will be managed within legal and ethical considerations. Carefully review this 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, income, living expenses, and 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. NI has a client complaint policy. You can request a copy of it, or download it from 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.

7. 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 NI in writing at homesource@neighborimpact.org. The opt-out will not apply to actions already taken based on prior consent.

 

RELEASE OF INFORMATION TO THIRD PARTIES

1. You understand and agree that NI 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 NI 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, OHCS, NWA, NP, CSBG, City of Bend, HSCP, NeighborWorks Umpqua, DevNorthWest, RootedHomes, Thistle & Nest, Habitat for Humanity, First Story, and other grant administrators, funders and private foundations.

3. You give permission to grant administrators and/or their agents to contact you, as needed, up to three years after conclusion of program participation, for program evaluation.

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

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

I authorize NeighborImpact to:

• Pull my (our) credit report(s) for all applicable services provided, at various times as needed.

• Obtain a copy of the final Closing Disclosure Statement, Appraisal, and Real Estate Note(s) when I purchase a home from the lender who made me/us a loan or the title company that closed the loan.

• Obtain a copy of the final Closing Disclosure Statement for the Home Equity Conversion Mortgage (HECM) from the lender who made me/us a loan or the title company that closed the loan.

This consent is voluntary and shall remain in effect until it is revoked or up to three years after conclusion of program participation in NeighborImpact’s services. 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.

Questions? Call: (541)323-6567 between the hours of 8:30am and 4:30pm Mon-Fri or  e-mail: homesource@neighborimpact.org