2013 homebase registration form

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Primary Registrant Name:

Date of Birth:

Home Phone:

Cell Phone:

Work Phone:

Email 1:

Email 2:

Gender: □ Male □ Female □ Transgender

Race: (check all that apply) □ White □ Asian □ African American/Black □American Indian / Alaska Native □ Native Hawaiian / Pacific Islander □ White & Asian □ White & AA / Black □American Indian / Alaska Native & White □ Other Multiple Race: □ Decline to Respond

Employment Status: (select best response) □ Self-employed □ Work full-time for employer □ Work part-time for employer □Homemaker □ Full-time student □ Permanently unable to work □ Unemployed and seeking work □ Unemployed and not seeking work □ Retired

Educational Attainment: □ less than HS Diploma □ HS Diploma or equivalent □ Some post-secondary education □ Certification from a vocational or technical training program □ Associate’s Degree □ Bachelor’s Degree □ Master’s or other graduate degree □ Decline to Respond

Ethnicity: □ Hispanic □ Not Hispanic □ Decline to Respond

Marital Status: □ Single □ Married / Domestic Partners □ Divorced □ Legally Separated

SSN#: - -

Credit Score (if known):

How many times have you been late with your bill payments in the last year?: □ Never □ Once □ 2-3 Times □ 4 or more times

How much do you typically pay on your credit card monthly bills?: □ The full balance □ Less than the full balance, more than the minimum required □ The minimum required □ Less than the minimum required □ Don’t have a credit card

Have you ever been involved in the foreclosure process?: □ Yes □ No If yes, when:

Have you declared bankruptcy in the past 7 years? □ Yes □ No If yes, when?

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Co-Registrant or Significant Other

Name:

Date of Birth:

Home Phone:

Cell Phone:

Work Phone:

Email 1:

Email 2:






SSN#: - -

Credit Score (if known):

How many times have you been late with your bill payments in the last year?: □ Never □ Once □ 2-3 Times □ 4 or more times

How much do you typically pay on your credit card monthly bills?: □ The full balance □ Less than the full balance, more than the minimum required □ The minimum required □ Less than the minimum required □ Don’t have a credit card

Have you ever been involved in the foreclosure process?: □ Yes □ No If yes, when:

Have you declared bankruptcy in the past 7 years? □ Yes □ No If yes, when?

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Debts

Please list all your household debt balances below:

Credit cards: $ Line of credit: $

Student loans: $ Child Support / Alimony (paid): $

Auto loans: $ Other: $ What is this debt?

Assets

Total Value of All Accounts

Checking Accounts: $ Investment: $

Savings Accounts: $ Real Estate: $

Retirement Accounts: $ Other: $

Amount saved for buying a home? $

Additional Employment and Other Sources of Income

Other Employer: Co-Applicant Other Employer:

Job Title: Job Title:

Years on Job: Years on Job:

Years in Profession: Years in Profession:

Wage: □ Salary □ Hourly □ Commission Wage: □ Salary □ Hourly □ Commission

Average hours worked per week: Average hours worked per week:

Gross Monthly Income: $ Gross Monthly Income: $

Other Income Sources (all household members)

Unemployment: Social Security / SSDI:

Dividend / Interest: Alimony / Child Support:

Rental Income: Other:

Employment

Current Employer: Co-Applicant Current Employer:

Job Title: Job Title:

Years on Job: Years on Job:

Years in the Profession: Years in the Profession:

Wage: □ Salary □ Hourly □ Commission Wage: □ Salary □ Hourly □ Commission

Average hours worked per week: Average hours worked per week:

Gross Monthly Income: $ Gross Monthly Income: $

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General Household and Intake Questions

How did you hear about our program?: □ Homeowner or Staff Member □ Word of Mouth □ Real Estate Listing – MLS □ Real Estate Listing – Craigslist or Other □ Poster/Flyer □ Event □ Internet Search □ Newspaper / Magazine Ad □ Radio or TV Ad □ Radio or TV PSA □ News Article □ Lender □ Real Estate Agent □ Agency / Nonprofit □ Homebuyer Education Person/Organization who referred you: ________________________________________

Are you or your spouse first time home buyers (meaning you have not owned a home in the past 36 months)?

What is the primary language spoken in your household?

Are any other languages spoken in your household?

Will you require a translator to do business with HomeBase? □ Yes □ No

Do you claim a Female Head of Household on your tax return?:

Does any household member have special needs?: if Yes, check description: □ Physical Disability □ Developmental Disability □ Mental Disability

What is your desired number bedrooms?

What is your desired number bathrooms?

What is the most important to you about the neighborhood where you purchase? (select top 3) □ Schools □ Safety / crime □ Proximity to work / school □ Proximity to amenities □ Proximity to family / friends □ Strong housing market □ Part of a community land trust program

What is your primary reason for purchasing a home?

Quality of living situation: □ Good □ Adequate □ Poor □ Overcrowded

Current Housing Type: □ House □Apt □ Condo □ Mobile □ Shelter □ Govt/Sect 8

Current Rent: $ per month Lease Expiration Date:

Utilities included in Rent? □ Yes □ No □ Unknown Current Utilities/month $

How many bedrooms: and bathrooms: are in your current home?

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Residence History for 3 Years

(if you have been at your current address less than 3 years)

Current Address: Current (Co-Applicant)Address:

Dates Occupied: to Dates Occupied: to

Check One: □ Rent □ Own □ Live Rent Free Check One: □ Rent □ Own □ Live Rent Free

Landlord Contact Name: Landlord Contact Name:

Landlord Contact Number: Landlord Contact Number:

Housing payment: $ Housing payment: $

Previous Address: Previous (Co-Applicant)Address:


















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Additional Household Members

Name: Name: Name:

Relation to Registrant: Relation to Registrant: Relation to Registrant:

Date of Birth: Date of Birth: Date of Birth:
















If under 18: School District:



School: School: School:

Grade Level: Grade Level: Grade Level:

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Name: Name: Name:

Relation to Registrant: Relation to Registrant: Relation to Registrant:

Date of Birth: Date of Birth: Date of Birth:



















School: School: School:

Grade Level: Grade Level: Grade Level:

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References

To help us get back in touch with you in the future, we would like to collect the names, telephone numbers, and

addresses of three people who will know how to reach you. Please tell me about people who live at different addresses.

This information will be kept strictly confidential and will only be used if we are unable to contact you.

Additional Reference #1

Name: _____________________

Street Address: ____________________________ Apt # _______

________________________________________________

Telephone Number: (_______) ________-________

Cell phone number: (_______) ________-________

Email address: ______________________________________________


Name: _____________________


________________________________________________



Email address: ______________________________________________


Name: _____________________


________________________________________________



Email address: ______________________________________________

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Full Disclosure

I, __________________________________ certify and attest that the following statements are true and correct: (Print Registrant Name) I, __________________________________ certify and attest that the following statements are true and correct: (Print Co-Registrant Name) I have disclosed any and all income sources for income that I am currently receiving, taxable or non-taxable. I have disclosed all of my asset accounts and I understand that there is a maximum liquid asset restriction as a requirement of this program. I have disclosed all of the household members that will be residing in the home, or will potentially be residing in the home at the time of closing, and if said members are over the age of 18, I have disclosed their income to the best of my knowledge. I certify that I have not falsified any information on this application and I acknowledge that if any of the information within this application is found to be false that my application may be subsequently denied. I understand that any changes to my financial situation during the approval process, including but not limited to, an increase/decrease in income, or an increase/decrease in assets, could affect my application. I understand that I may be required to submit additional documentation to verify employment, income, and assets or any additional information deemed necessary to make such eligibility determination. I understand that income certification is valid for six months, or until I have a signed contract for purchase, whichever occurs first. I understand and agree that HomeBase and its related entities, the City of Austin, Austin Housing Finance Corporation, or any agency or authority it has designated to act on its behalf reserves the right to revise or revoke its eligibility determination based on any information received after a certification determination is made, including discovery of false information. The information contained and programs described herein are intended as a general descriptions relating to affordable housing, are current as of the date of preparation hereof to the knowledge of HomeBase and are subject to change without notice. HomeBase, its affiliates, employees and consultants make no warranties or representations of any kind or nature whatsoever regarding the information contained and programs described herein. The source of my minimum contribution and funds to close will come from the following source: _____________________________________________________________ (Depository/Bank/Financial Institution Name) These funds are from my / our: □ Checking □ Savings □ Retirement □ Gift __________________________________ __________________________________ Registrant Signature Co-Registrant Signature _______________ ________________ Date Date

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HomeBase Privacy Policy & Disclosure

We are concerned about and respect the privacy of our customers’ personal financial information. We understand that

our customers furnish sensitive information to us in the course of daily business, such as purchasing a home and

owning a HomeBase home, and we are committed to treating such information responsibly. We know that our

customers expect privacy and security for their personal financial affairs.

We will take all the necessary steps to safeguard sensitive information that has been entrusted to us by our customers.

The following privacy policy and disclosure outlines our practice regarding personally identifiable financial information

for consumers and those consumers who become our customers.

TYPES OF INFORMATION HOMEBASE COLLECTS

We collect nonpublic personal information from many sources. We collect nonpublic personal information directly

from consumers on various applications and forms and from source documentation provided by the consumer, for

example, homebuyer application, income verification forms, wage statements, tax documents, and requests for

information about products and services.

We collect information as a result of a transaction between us and our customers and as a result of providing a product

or service to our customers. This includes transaction information from other loans between us and our customers.

We collect information from credit reporting agencies.

Nonpublic personal information does not include that which we obtain from government records, widely distributed

media, or government-mandated disclosures.

TYPES OF INFORMATION HOMEBASE DISCLOSES

We do not disclose any nonpublic financial information about our current or former customers to nonaffiliated third

parties except as permitted by law. We may disclose certain personally identifiable information without allowing

consumers the right to opt out of our sharing agreements in the following circumstances:

To certain nonaffiliated third parties (under limited circumstances) to the extent permissible under law to service the account, report to credit bureaus, manage risk, and perform other financial service related activities.

To disclose information that we receive on a customer’s application such as customer’s assets, liabilities, income and employment history in order to determine whether a loan made to the client meets underwriting criteria, for example.

To disclose information necessary to enforce our legal or contractual rights or the right of any other person who is engaged in the financial transaction.

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To disclose information required in the ordinary course of business, such as in the settlement of claims or benefits or the confirmation of information to the consumer or the consumer’s agent.

To provide information to agencies, persons that are assessing our compliance with industry standards, and our attorneys, accountants, and auditors.

To the extent permissible under the Right to Financial Privacy Act. To a consumer reporting agency under the Fair Credit Reporting Act. To comply with federal, state, or local laws, rules, and other applicable legal requirements.

SAFEGUARDING CUSTOMER INFORMATION

We protect consumer privacy by ensuring that only employees who have a business reason for knowing information

have access to it. We have appointed HomeBase’s Executive Director as the financial privacy coordinator, who is

responsible for maintaining internal procedures to ensure that our customers’ information is protected. For example,

information in loan files can only be accessed by employees who work in the fixed-rate equity loan origination and

operations department.

All employees have a copy of this policy and are trained at least annually regarding the importance of safeguarding

customer information. Any employee who violates our privacy policy is subject to disciplinary action.

If we change our policy or practice by, for example, adding a category of information that will be disclosed to a third

party, we will notify existing customers and give them an appropriate time period to opt out of the disclosure.

________________________________ _________________________________

Signature Date

_________________________________ _________________________________

Signature Date

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Consent for Participation in Research and Data Collection Efforts Purpose of the research: You are being asked to participate in a research study about homeownership, being conducted by the Urban Institute on behalf of NCB Capital Impact and HomeBase. The purpose of this research is to study the impact of the HomeBase program on the people who purchase homes from this program. Reason you are being asked: You have been asked to participate in the research because you are interested in purchasing a home. We want to understand how purchasing a “shared equity” property affects homeowners’ finances. We also want to compare those who purchase shared equity properties to those who do not. Procedures: If you agree to participate in this research, we would ask you to do the following things:

1. Answer a few questions so that we can obtain your contact information and better understand your financial background.

2. Additional information will be collected about you by HomeBase if you decide to purchase a home through the program. This may include information about the price of the home you may purchase, your down payment, and mortgage.

3. Authorize us to do a “soft pull” of your credit history. This “soft pull” will not affect your credit score. This information will help us to understand your financial background and ability to purchase a home.

4. To complete a follow-up survey, scheduled for 2016, we will ask you to give us names and contact information of people who can help us get in touch with you. We will contact these people only if we are unable to reach you directly. If you agree to participate in the research, you agree to allow us to contact you for future surveys and collect data from public agencies for up to ten years.

If there are any questions that you do not wish to answer in the survey, you can just ask to move to the next one. Your decision to participate or opt-out of this research study will in no way affect the services provided to you by this organization. You can also contact Mr. Brett Theodos at the Urban Institute with any additional questions (bthedos @ urban.org or 202-261-5865). Privacy and confidentiality: Your answers will be strictly confidential. This means that only people working on this study will see them. At the end of the study, we will combine all the data together and make sure that no information that can identify you. No results presented from this study will ever identify specific participants. The only people who will know that you are a research subject are members of the research team at the Urban Institute, the staff of HomeBase, and NCB Capital Impact. No information about you, or provided by you during the research, will be disclosed to others without your written permission, except if required by law. Our team members have gone through training about protecting your privacy and confidentiality. Any information that is obtained by this study and that can be identified with you will remain confidential and will be disclosed only with your permission or as required by law. Potential risks: A state of the art security plan is in place and every effort will be made to secure the information that is collected to prevent disclosing you data to people who are not part of the research team. We do have to let you know however, that there is always a chance—though quite a small one—that your information will be inadvertently disclosed to people who are not part of the research team. Potential benefits:

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Your participation will help researchers and policy makers understand a homeownership program for which currently no other data or research exists. There are no direct benefits to completing the application survey and allowing us to access your credit and other data. You will receive a $40.00 gift card for completing the follow-up telephone survey as a token of appreciation. Withdrawal from the study: You can choose whether to be in this study or not. If you volunteer to be in this study, you may withdraw at any time without consequences of any kind. You may also refuse to answer any questions you don’t want to answer and still remain in the study. Signature of Subject: I have read (or someone has read to me) the above information. I been given an opportunity to ask questions and my questions have been answered to my satisfaction. I have been given a copy of this form. If I have any questions about this study, I may contact Mr. Brett Theodos at btheodos @ urban.org or 202-261-5865.

I agree to be contacted for future surveys for up to ten years. I agree to allow the Urban Institute to contact the individuals I list as contacts on the application survey, in case the interviewer and I lose touch. I understand that information about me will be collected from HomeBase and shared with the research team for up to ten years. I agree to allow the Urban Institute to do a “soft pull” of my credit history (which will not affect my credit score) from a third party credit reporting agency. I agree to answer intake questions.

___________________________ _________ Signature Date ___________________________ Printed Name ___________________________ _________ Signature of Program Staff Person Date

___________________________

Printed name of Interviewer

NOTICE TO BORROWERS: This notice to you as required by the Right to Financial Privacy Act of 1978 that HUD/FHA has a right of access to financial records held by financial institutions in connection with the administration of assistance to you. Financial records involving your transaction will be available to HUD/FHA without further notice or authorization but will not be disclosed or released by this institution to another government agency or department without your consent except as required or permitted by law.

Borrower's Certification & Authorization Certification

The undersigned certify the following:

1. I/We have applied for a mortgage loan from ____________________________, herein referred to as the “Lender”. In applying for the loan, I/We completed a loan application containing various information on the purpose of the loan, the amount and source of the down payment, employment and income information, and assets and liabilities. I/We certify that all of the information is true and complete. I/We made no misrepresentations in the loan application or other documents, nor did I/We omit any pertinent information.

2. I/We understand and agree that the Lender reserves the right to change the mortgage loan review process to a full documentation program. This may include verifying the information provided on the application with the employer and/or the financial institution.

3. I/We fully understand that it is a Federal crime punishable by fine or imprisonment, or both, to knowingly make any false statements when applying for this mortgage, as applicable under the provisions of Title 18, United States Code, Section 1014.

AUTHORIZATION TO RELEASE INFORMATION To Whom It May Concern:

1. I/We have applied for a mortgage loan from, ____________________________, herein referred to as the “Lender”. As part of the application process, the Lender may verify information contained in my/our loan application and in other documents required in connection with the loan, either before the loan is closed or as part of its quality control program.

2. I/We authorize you to provide the Lender and to any investor to whom the Lender may sell my/our mortgage, any and all information and documentation that they request. Such information includes, but is not limited to, employment history and income; bank, money market, and similar account balances; credit history; and copies of income tax returns.

3. The Lender or any investor that purchases the mortgage may address this authorization to any party named in the loan application.

4. A copy of this authorization may be accepted as an original.

5. Your prompt reply to the Lender or the investor that purchased the mortgage is appreciated. ______________________________________________________ ____________________ Borrower Date SSN ______________________________________________________ ____________________ Borrower Date SSN ______________________________________________________ ____________________ Borrower Date SSN ______________________________________________________ ____________________ Borrower Date SSN

2013 homebase registration form

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