Date of Workshop: ______Landlord Education Class

CUSTOMERPlease Print Clearly

Name: ______

First MI Last

______

StreetApt.CityStateZip Code

Home: (_____) ______–______Work: (______) ______–______Mobile/Cell(_____) ______–______

Email: ______Preferred contact type: Home phone Cell Phone Work E-mail

______

D.O.B. ______/______/______Age: ______Disabled? Yes No US Veteran Yes No Active Military? Yes No

Gender _____Female _____Male Preferred Language (If other than English): ______

Are you English proficient? Yes or No Do you live in a rural area? Yes or No

Race:_____ White _____ Black/African American and White _____ Black or African American _____ Native Hawaiian/Other Pacific Islander _____ American Indian/Alaskan Native _____ American Indian/Alaskan Native and White _____Asian _____ American Indian/Alaskan Native and Black _____ Asian and White _____ Other: ______

Ethnicity: Hispanic Origin (please make sure you have also selected a Race above): YesNo

Marital Status: _____ Single _____ Married _____ Divorced _____ Separated _____ Widowed

Citizenship:_____US Citizen _____Non-Resident Alien _____Permanent Resident Alien

Foreign Born?_____Yes_____No

Country of Origin (answer only if you are foreign born): ______

Current Housing Arrangement: _____Rent _____Homeowner with mortgage paid off _____Homeless

_____Homeowner with mortgage_____Living with family member and not paying rent

Household Type (please select the most accurate)?

_____Female headed single parent household _____Married with Dependents _____Male headed single parent household

_____Married without Dependents _____Single adult _____Two or more unrelated adults_____ Other: ______

Annual Family or Household Income: $______Employer:______

Job Title: :______First Date Employed: ______

Family/Household Size:______How many dependents(other than those listed by any co-borrower)? ______

Are there non-dependents who will be living in the home?YesNoIf yes, list below:

______

RelationshipAgeRelationshipAge

Highest Education Level:Below High School DiplomaHigh School DiplomaGED

Some College (no degree)Vo/Tech CertificateAssociates Degree (2-year)

Bachelors Degree (4-year)Masters DegreeOther: ______

Referred to by (please circle all that apply): Print AdvertisementGovernmentTVRealtorProperty Owners Meeting

Staff/Board member Walk-InFriend Radio Newspaper Article Direct MailingBank:Other:______

Are you a first Time Buyer: YesNoOwned a home in last 3 years?YesNo

Landlord Education Class cont.page 2

CO-APPLICANT (complete ONLY if property has/will have a co-owner)

Name: ______

First MI Last

______

StreetApt.CityStateZipCode

Home: (_____) ______–______Work: (______) ______–______Mobile/Cell (_____) ______–______

Email: ______Preferred contact type: Home phone Cell Phone Work E-mail

Relationship to Customer: _____Spouse _____Boyfriend/Girlfriend _____Significant Other _____Daughter _____Son_____Sister/Brother _____Mother _____Father _____Other:______

______

D.O.B. ______/______/______Disabled ? YesNoUS Veteran?Yes No

Gender _____Female _____Male Preferred Language (If other than English): ______

Race:_____ White _____ Black/African American and White _____ Black or African American _____ Native Hawaiian/Other Pacific Islander _____ American Indian/Alaskan Native _____ American Indian/Alaskan Native and White _____Asian _____ American Indian/Alaskan Native and Black _____ Asian and White _____ Other: ______

Ethnicity: Hispanic Origin (please make sure you have also selected a Race above): YesNo

Marital Status: _____ Single _____ Married _____ Divorced _____ Separated _____ Widowed

Citizenship:_____US Citizen _____Non-Resident Alien _____Permanent Resident Alien

Foreign Born?_____Yes_____No

Country of Origin (answer only if you are foreign born): ______

Current Housing Arrangement: _____Rent _____Homeowner with mortgage paid off _____Homeless

_____Homeowner with mortgage_____Living with family member and not paying rent

Household Type (please select the most accurate)?

_____Female headed single parent household _____Married with Dependents _____Male headed single parent household

_____Married without Dependents _____Single adult _____Two or more unrelated adults_____ Other: ______

Annual Family or Household Income: $______Employer:______

Job Title: :______First Date Employed: ______

Family/Household Size:______How many dependents(other than those listed by any co-borrower)? ______

Are there non-dependents who will be living in the home?YesNoIf yes, list below:

______

RelationshipAgeRelationshipAge

Highest Education Level:Below High School DiplomaHigh School DiplomaGED

Some College (no degree)Vo/Tech CertificateAssociates Degree (2-year)

Bachelors Degree (4-year)Masters DegreeOther: ______

HDF Pre-Purchase Counseling cont.Page 3

ADDITIONAL INFORMATION

New Property Address:

Street CityStateZip Code

What type of residence is it? Single FamilyCondoMulti-Family (# of Units ) Anticipated rental income

Expected Closing Date:

What other types of classes would you be interested in attending? (Circle as many as applicable):

General Budgeting & CreditHome MaintenanceHow to Hire a Contractor

Specific Landlording Issues (please specify):

Other specific issues (please specify):

TOTAL COST & FINANCING

Monthly Payments:

Name of Lender / Amount / Interest Rate / Term / 1st Mortgage: $______
1st / $ / 2nd Mortgage: $______
2nd CHFA / $ / Mortgage Ins. $______
3rd / $ / Taxes $______
Cash (down payment) / $ / Condo Fees (if applies) $______
Cash from seller / $ / Home Insurance: $______
Monthly Payment: $______

Total out of pocket = $

Purchase Price:$

Closing Cost:$Appraised Value: $

Total:$Prior Rent per month:$

RECEIPT OF INSPECTION FORMS

I acknowledge with Neighborhood Housing Services of New Britain, Inc that I have received the following forms: (Please Initial)

_____ (a) ‘For Your Protection: Get a Home Inspection’; and

_____ (b) ‘Ten Important Questions to Ask Your Home Inspector’

AUTHORIZATION/

By signing below, I/we authorize Neighborhood Housing Services of New Britain, Inc. to share my/our demographic information with sponsors and potential lenders.

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, and Section 1001.

______

CustomerDate

______

Co-ApplicantDate

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