Financial Resource Center

986 Doyle Street

Orangeburg, SC 29115
mbolen@southeasternhcd.org
(803)259-4623 Phone
(803)591- 0419 Fax

Pre-Purchasing Counseling Application

NOTE: If you have impairment, disability, language barrier, or otherwise require an alternative means of completing this form or accessing
information about housing counseling, please talk to your housing counselor about arranging alternative accommodations.

How did you hear about our housing counseling agency?

Member of our staff Print / Radio ad Religious or social organization Friend / Family
HUD Bank or mortgage servicer Internet Search Other Specify ____________

Part One. Your Biographic and Demographic Information

Name 1 : Date:
Last Name First Name Middle Name
Home Phone:

Address : Cell Phone:

Address and Apartment No City & State Zip
Work Phone:
Social Security :
Best Time:
Email :
Date of Birth:
Preferred Contact : Home Phone Cell Phone Work Phone Email Text
Gender: Male Female
Race : American Indian/Alaska Native Asian African American
Ethnicity: Mexican Puerto Rican
Native Hawaiian/Pacific Islander White Biracial or Multiracial
Veteran: Yes No
Other (Specify): Decline to Answer
Active Military: Yes No
Marital Status : Single Married Divorced Separated Widow
Disabled: Yes No

Name 2 : Home Phone:

Last Name First Name Middle Name
Cell Phone:
Address :
Address and Apartment No City & State Zip Work Phone:

Best Time:
Social Security :
Date of Birth:
Email :
Gender: Male Female
Preferred Contact : Home Phone Cell Phone Work Phone Email Text
Ethnicity: Mexican Puerto Rican
Race : American Indian/Alaska Native Asian African American
Veteran: Yes No
Native Hawaiian/Pacific Islander White Biracial or Multiracial

Other (Specify): Decline to Answer Active Military: Yes No

Disabled: Yes No
Marital Status : Single Married Divorced Separated Widow

Relationship to Applicant:

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 Financial Resource Center
986 Doyle Street
Orangeburg, SC 29115
mbolen@southeasternhcd.org
(803)259-4623 Phone
(803)591- 0419 Fax

Highest Education Level Highest Education Level

for Name 1: for Name 2:

Address in Rural Area: Yes No Address in County of:

1st Time Home Buyer: Yes No 1st Generation Home Buyer: Yes No

English Proficiency: Yes No

Part Two. Your Housing Status and Housing Goals

Household Type:
Single Cohabitating Single Male Headed Non-Spousal family members

Married Roommates / Non Relative Single Female Headed Other: Specify:

Household Size: Adults: Children:

Male Female Age: Male Female Age:
Male Female Age: Male Female Age:
Male Female Age: Male Female Age:
Male Female Age: Male Female Age:

My current housing status is:

Renting/leasing Homeowner with mortgage(s) Homeowner (no mortgage debt)
Homeless Boarder (renting) Living with family (renting/not renting)
Other Receiving assistance subsidies? No Yes Specify:

My housing goal is to...check all that apply:

Buy a home (pre-purchase counseling) Prevent foreclosure Obtaining rental housing

Transition from homelessness Obtain a reverse mortgage Get credit counseling

Discuss a fair housing rights violation

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 Financial Resource Center
986 Doyle Street
Orangeburg, SC 29115
mbolen@southeasternhcd.org
(803)259-4623 Phone
(803)591- 0419 Fax

Part Three. Your Rental and Mortgage Information

Renting: Yes No
Renting for Years: ____ Months: ____
Pay market rent Section 8 recipient Receive rent subsidy/public housing
I need assistance with delinquent rent I need assistance with delinquent utilities Facing eviction
I am interested in filing a fair housing claim. Housing Choice Voucher: Yes No
List Reasons for Fair Housing Claim: ______________________________________________________________

Mortgage: Yes No
If you have said NO to Mortgage you can go to Credit History Questions.
First Mortgage Second Mortgage
Is this loan Current or Delinquent? Current Delinquent Current Delinquent
Mortgage servicer name:
Loan Number
Loan Balance
Interest Rate
Monthly principal and interest
payment (excluding
taxes/insurance)
Mortgage Insurance payment
(PMI)
Fixed or Adjusting Interest Rate: Fixed Adjusting Fixed Adjusting
Date you last made payment:
Past Due Amount:
Have you applied for a loan Yes No Yes No
modification or forbearance?
Details:
Default Reason:
Divorce / Marital Separation Disability Decreased Income Increased Expenses Medical Other

Has your hardship ended? Yes No

Do you have the ability and willingness to resume mortgage payments? Yes No
If No: Are you seeking an alternative outcome, such as deed-in lieu of foreclosure or short sale?
Explanation of alternative outcome: ___________________________________________________________________
Credit History Questions:
1. Are there any outstanding judgments on you? Yes No Don’t Know
2. Declared bankruptcy within the past seven years? Yes No
3. Property foreclosure or surrendered through deed-in-lieu within the past 7 years? Yes No
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 Financial Resource Center
986 Doyle Street
Orangeburg, SC 29115
mbolen@southeasternhcd.org
(803)259-4623 Phone
(803)591- 0419 Fax

Part Four. Your Employment Status

Name 1’s Employment Status:

Employed Full-Time Seasonal Employed Part-Time

Unemployed, receiving benefits Self-Employed Unemployed, not receiving benefits

Disabled, receiving benefits Retired Other:

Current Employer: Dates:

Address: Phone:
Street Address City & State Zip

Previous
Employer: Dates:

Address: Phone:
Street Address City & State Zip

Name 2’s Employment Status:

Employed Full-Time Seasonal Employed Part-Time
Unemployed, receiving benefits Self-Employed Unemployed, not receiving benefits
Disabled, receiving benefits Retired Other:

Current Employer: Dates:

Address: Phone:
Street Address City & State Zip

Previous
Employer: Dates:

Address: Phone:
Street Address City & State Zip

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 Financial Resource Center
986 Doyle Street
Orangeburg, SC 29115
mbolen@southeasternhcd.org
(803)259-4623 Phone
(803)591- 0419 Fax

Part Five. Monthly Income and Monthly Debts

Name One Name Two

Monthly Income Monthly Income
Gross Net Gross Net
Income Type (Before Taxes (After Taxes & (Before Taxes (After Taxes &
& Deductions) Deductions) & Deductions) Deductions)

1. Salary/Wage Earnings:
2. Child Support/Alimony:
3. Social Security:
4. Pension Income:
5. Dependents SSI Income:
6. Disability Income:
7. Unemployment Income:
8. SNAP (Food Stamps):
9. TANF/FI:
10. Other:
11. Other:
Total: $ $ $ $

Total Combined Gross: $

Total Combined Net: $

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 Financial Resource Center
986 Doyle Street
Orangeburg, SC 29115
mbolen@southeasternhcd.org
(803)259-4623 Phone
(803)591- 0419 Fax

Average Monthly Refer to your combined net income on

the previous page. Subtract your
Debts Name 1 Name 2 combined costs as added on the right.
Car Insurance: This represents your monthly cash
Car Payment(s): flow. Complete the calculation below:

Gas / Transportation: Combined monthly net income:

Alimony/Child Support:
$
Credit Cards Min Payments:
School Tuition:
Rent: Subtract monthly costs of:
Mortgage Payment:
$
Property Tax HOA Insurance:
Student Loan Debt:
Medical Debt: Equals:
Tithing: $
Food Average:
Childcare/ Daycare:
Cell Phones: I / We have a
Utilities All Combined: Positive Negative
Other: Cash Flow
Total Costs: $ $
Total Combined Costs: $

Total Value, Liquid Assets: Total Value, Hard Assets

Stocks Bonds CDs: $ Owner Occupied Property Value: $
Checking Accounts: $ Investment Property Value: $
Savings Account: $ Automobiles: $
IDA Savings: $ Life Insurance: $
401(k): $ Other: $
Total Value: $ Total Value: $

Client One Signature Date

Client Two Signature Date

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 Financial Resource Center
986 Doyle Street
Orangeburg, SC 29115
mbolen@southeasternhcd.org
(803)259-4623 Phone
(803)591- 0419 Fax

Data Release Form and Third Party Authorization

Note: If you have impairment, disability, language barrier, or otherwise require an alternative means of completing this
form or accessing information about housing counseling, please talk to your housing counselor about arranging
alternative accommodations.
You hereby authorize and instruct The Financial Resource Center (FRC)

□ Obtain and review your credit report, and

□ Request verifications of your income and rental history, and any other information deemed necessary
for improving your housing situation (for example, verifying your annual property tax obligations and
homeowner’s insurance fees)

Your credit report will be obtained from a credit reporting agency chosen by FRC. You understand and agree
that FRC intends to use the credit report for the purpose of evaluating your financial readiness to purchase or
rent a home and/or to engage in post-purchase counseling activities. You hereby authorize FRC to share your
credit report and any information that you provided (including any computations and assessments produced)
with the entities listed below in order to help FRC determine your viable financial options.

 Lenders  Banks  Mortgage Servicers

Debt Collectors  Landlords  Public Housing Authorities

Property Management Companies  Social Service Agencies  Counseling Agencies

Entities such as mortgage lenders and/or counseling agencies may contact your FRC counselor to evaluate the
options for which you may be eligible. In connection with such evaluation, you authorize the credit reporting
and/or financial agencies to release information and cooperate with your FRC counselor. No information will
be discussed about you with entities not directly involved in your efforts to improve your housing situation.

You hereby authorize the release of your information to program monitoring organizations of FRC, including
but not limited to, Federal, State, and nonprofit partners for program review, monitoring, auditing, research,
and/or oversight purposes. In addition you authorize FRC to have your credit report pulled two additional
times to conduct program evaluations. You also agree to keep FRC informed of any changes in address,
telephone number, job status, marital status, or other conditions which may affect your eligibility for a program
you have applied for or a counseling service that you are seeking.

Finally, you understand that you may revoke consent to these disclosures by notifying The Financial
Resource Center in writing.

Name (Printed) Social Security Signature Date

Name (Printed) Social Security Signature Date

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 Financial Resource Center
986 Doyle Street
Orangeburg, SC 29115
mbolen@southeasternhcd.org
(803)259-4623 Phone
(803)591- 0419 Fax

ENROLLMENT OF SERVICES
Based upon a review of your current qualification and your desired goals, it is agreed upon that your
next step is to enroll in:

 Pre-Purchase Homebuyer Counseling: This program allows for you to understand the
process and develop your plan for homeownership. This program will provide you with the
information necessary for you to fully understand the home purchase process. Enrollment
in this program will require 4 to 5 sessions with a housing counselor. These sessions may be
face to face or over the phone.

 Credit Counseling: This program allows for you to develop and individualized financial
management plant to responsibly handle debt and to resolve adverse reports to your credit.
The number of counseling sessions will be dependent on your individualized plan. This
program is a subset of Pre-Purchase counseling.

 Homebuyer’s Education Workshop: These workshops will provide you with the
information that you need to find, purchase and maintain a home. These workshops are
typically completed in one session. It is recommended that once successfully completed that
you enter into the Pre-Purchase Homebuyer Counseling.

 Budgeting Seminars: These seminars will allow you to obtain the tolls necessary in order
to become financially independent and free form money worries. These seminars are one
session. It is recommended that they be coupled with credit counseling. These seminars are
also ideal for anyone who wants to be fiscally responsible.

I have reviewed the requirements for the programs in which I am enrolled and agree to comply:

Client’s Signature Date

Counselor’s Signature Date

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 Financial Resource Center
986 Doyle Street
Orangeburg, SC 29115
mbolen@southeasternhcd.org
(803)259-4623 Phone
(803)591- 0419 Fax

HOUSING COUNSELING AGREEMENT

1. I understand that The Financial Resource Center provides housing counseling after which I may
receive a written action plan consisting of recommendations for handling my finances, possibly
including referrals to other housing or social services agencies as appropriate. I understand that I
am not obligated to access any of the services offered to me.

2. I understand that I will not be charged any fee for these services described in the Agreement. The
Financial Resource Center may be required to share some of my personal information with
representatives from funding sources for purposes of program monitoring, compliance and
evaluation.

3. A counselor of The Financial Resource Center may answer questions and provide information
relevant to my housing concerns, but the counselor will not give legal advice. If I want legal advice,
I will be referred for appropriate assistance, or I will seek legal counsel through other means.

4. I understand that The Financial Resource Center is not a financial or real estate service program
or provider, and that is provides information and education on numerous financial products and
housing programs solely as part of its overall counseling services, and I further understand that the
housing counseling I receive from The Financial Resource Center is no way obligates me to choose
any of these particular financial products or housing programs, nor does The Financial Resource
Center endorse or recommend any specific product or program or provider, regardless of whether
it is described or mentioned during counseling activities.

5. I acknowledge that I will receive a copy of The Financial Resource Center Housing Counseling
Privacy Policy, which is attached to this Agreement as Exhibit A.

Client’s Signature Date

Client’s Signature Date

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 Financial Resource Center
986 Doyle Street
Orangeburg, SC 29115
mbolen@southeasternhcd.org
(803)259-4623 Phone
(803)591- 0419 Fax

PROGRAM DISCLOSURE
Purpose of Housing Counseling: I/We understand that the purpose of the housing counseling program is to
provide one-on-one counseling to help customers fix those problems that prevent affordable mortgage
financing. The counselor will analyze my/our financial and credit situation, identify those barriers preventing
me/us from obtaining affordable mortgage financing, and develop a plan to remove those barriers. The
counselor will also provide assistance in management with the preparation of a monthly and manageable
budget plan. I/We further understand that it will not be the responsibility of the counselor to fix the problem
for me/us but rather to provide guidance and education to empower me/us in fixing those issues preventing
affordable mortgage financing.

Customer's Responsibility: I/We understand that it is our responsibility to work in conjunction with the
counseling process and that failure to cooperate will result in the discontinuation of my counseling program.
This includes, but is not limited to, missing three consecutive appointments.

Our Services include:

Pre-Purchase Counseling- Assists with resolution to barriers of homeownership

through one-on-one counseling. This includes a complete evaluation of your financial
status and readiness for homeownership.

Financial, Budgeting and Credit Workshops- Financial, Budgeting and Credit

Workshops provide general information about budgeting tools, credit reports, factors
that impact credit scores and various financial resources.

Pre-Purchase Homebuyer Education Workshops- Pre purchase education

provides general information about the home buying process to a group of potential
homebuyers, in a classroom setting. This includes, but is not limited to, information on
down-payment assistance programs, closing costs. home inspections, credit readiness,
and various financing options.

Financial Management/Budget Counseling- This program allows for you to

develop an individualized financial management plan to responsibly handle debt and to
resolve adverse reports to your credit. The number of counseling sessions will be
dependent on your individualized plan.

Rental Housing Counseling- Assists with determining what is best for your housing
needs and your financial status. If a determination that rental is the best housing option,
rental counseling will assist in the understanding of lease provisions, housing quality
standards, and various landlord and tenant rights and responsibilities.

Rental Housing Workshops- Rental Housing Workshops provides general

information about the pros and cons of rental housing versus homeownership in a
classroom setting.

Please place an X beside the services that you are interested in.

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 Financial Resource Center
986 Doyle Street
Orangeburg, SC 29115
mbolen@southeasternhcd.org
(803)259-4623 Phone
(803)591- 0419 Fax

Clients are not obligated to receive any additional services offered by this agency or its exclusive partners to
receive housing counseling. In addition to our housing counseling program, Southeastern Housing and
Community Development also provide the following services:
1. Rental Housing
2. Lease Purchase Program
3. Individual Development Accounts (Matched Savings Program)
4. Home Sales
5. Owner Occupied Repairs

Applicant Signature: Date:

Co-Applicant Signature: Date:

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