Twin Cities Habitat for Humanity Mortgage Foreclosure Prevention Program 1954 University Ave W, St. Paul, MN 55104 Phone and Fax: 612-305-7189 http://www.tchabitat.org/mfpp
MORTGAGE FORECLOSURE PREVENTION PROGRAM TRIAGE FORM
Please complete the following questions to the best of your ability. If you don’t know an answer, just leave it blank. If an answer doesn’t apply, put “N/A”
What is today’s date?	How did you hear about us?	Are you a Habitat Homeowner?
☐ Yes	☐ No
Do you live in the property?	If not, who lives there?
☐ Yes	☐ No
Are you on the mortgage?	If you aren’t on the mortgage, who is?
☐ Yes	☐ No
If you aren’t on the mortgage, what is your connection to the property?
Are you working with any other foreclosure prevention agencies or attorneys? If yes, who?
ADDRESS OF PROPERTY YOU’RE CONTACTING US ABOUT
House #	Street Name	City	State	Zip
PARTICIPANT 1	PARTICIPANT 2
What is your name?	What is your name?
Date of Birth	Last 4 of Social	Date of Birth	Last 4 of Social
Best Phone Number	Best Phone Number
Email Address	Email Address
What is your race or ethnicity?	What is your race or ethnicity?
Are you Hispanic?	Marital Status	Are you Hispanic?	Marital Status
☐ Yes	☐ No	☐ Yes	☐ No
Are you a veteran?	Do you have a disability?	Are you a veteran?	Do you have a disability?
☐ Yes	☐ No	☐ Yes	☐ No	☐ Yes	☐ No	☐ Yes	☐ No
What is your highest level of education?	What is your highest level of education?
Relationship to Participant 2	Relationship to Participant 1
Mailing Address (if different from property)	Mailing Address (if different from property)
House #	Street	House #	Street
City	State	Zip	City	State	Zip
Do you own or rent your current residence?	Do you own or rent your current residence?
Who lives in the property in question? .
Person Name	Relationship to You?	Gender	Date of Birth	Veteran?	Disability?
Do you want to keep the property?	Is the property for sale?
☐ Yes	☐ No	☐ Yes	☐ No
OTHER PROPERTIES OWNED BY EITHER PARTICIPANT
House #	Street Name	City	State	Zip	Owner
HAS EITHER BORROWER BEEN IN BANKRUPTCY?	☐ Yes	☐ No
Person Filing	Chapter Filed	Date of Filing	Discharge Date?
TELL US ABOUT ANY MORTGAGES AND OTHER LIENS ON YOUR PROPERTIES
Mortgage	Property/Mortgage 1	Property/Mortgage 2	Property/Mortgage 3
Property Address
Company Name
Loan Number
Payment
Interest Rate
Fixed or Adjustable Rate?
# Payments Behind
Amount Behind
Original Principal
Principal Remaining
Loan start date
Loan end date
FHA, VA, Fannie Mae, or Freddie Mac?
Heard from Foreclosure Attorney?	☐ Yes	☐ No	☐ Yes	☐ No	☐ Yes	☐ No
Sheriff’s Sale Date
Have you postponed your sale?	☐ Yes	☐ No	☐ Yes	☐ No	☐ Yes	☐ No
Last Refinance Date
Last Modification Date
Property Tax Yearly Amount?
Property Taxes Escrowed?	☐ Y	☐ N	☐ Y	☐ N	☐ Y	☐ N
Property Taxes Current?	☐ Y	☐ N	☐ Y	☐ N	☐ Y	☐ N
Homeowner’s Insurance Yearly Amount?
Homeowner’s Insurance Escrowed?	☐ Y	☐ N	☐ Y	☐ N	☐ Y	☐ N
Homeowner’s Insurance Current?	☐ Y	☐ N	☐ Y	☐ N	☐ Y	☐ N
Is the property in a Homeowners’ Association?	☐ Y	☐ N	☐ Y	☐ N	☐ Y	☐ N
Homeowner’s Association Dues Current?	☐ Y	☐ N	☐ Y	☐ N	☐ Y	☐ N
Homeowners’ Association Dues Monthly Amount:
Homeowners’ Association Dues Months Behind:
TELL US ABOUT ALL INCOME IN THE HOUSE
Employment Income
About	Job 1	Job 2	Job 3	Job 4
Employee Name
Job Title
Employer Name
Start Date
Type of Company
Hours per week
Monthly Pre Tax Income
Monthly Post Tax Income
Other Income (Social Security, rent, pension)
Person Receiving	Type of Income	Amount	Frequency
OTHER ASSETS
Tell us about other assets owned by the homeowners.
Asset	Whose Is It?	Value
Checking / Savings Account
Checking / Savings Account
Checking / Savings Account
Checking / Savings Account
Type of Asset	Whose is it?	Value
Tell us about your car(s)	Car 1	Car 2	Car 3
Owner
Owned or Leased?
Original Price
Payment Amount (if applicable)
Loan Balance Remaining
Year Car Paid Off or Lease Ends
Year
Make
Model
OTHER DEBTS
Tell about your other loans and credit cards.
Whose is it?	Type of Debt	Who is the money paid to?	Monthly Payment	Balance Remaining
REASON FOR CONTACTING PROGRAM (HARDSHIP)
Date Hardship Began	Date Hardship Ended	Have you talked to your bank?
☐ Yes	☐ No
Please tell us why you are concerned about your housing affordability.
If you have talked to your bank, what have they said? Have they mentioned a modification, repayment plan, or other method?

MONTHLY BUDGET
Name:	Date:
Address:	Counselor:
A. Type Of Income	Notes	Net Income	Gross Income
Total Income	Add Section A
B. Housing Expenses	Notes	Current	Balance
1st Mortgage
2nd Mortgage
Property Taxes
Homeowner's Insurance
Association Dues
Total Housing Expenses	Add Section B
C. Non Housing Expenses	Notes	Current	Balance
Rent Paid at Your Primary Residence
Total Mortgages Paid at Rental Properties
Electric
Heat / Gas
Water / Sewer / Trash
Phone
Cable/Internet/Satellite
Food / Groceries
Auto Payment
Gas / Oil for Auto / Bus Fare
Auto Insurance and Maintenance
Child Care
Child Support / Alimony
Health Insurance
Out of Pocket Medication / Copays
Home Maintenance and Supplies
Toiletries and Household Supplies
Other Insurance (Life, malpractice, etc)
Personal Loans
Credit Cards
Tuition / Student Loan Payments
Other
D. TOTAL NON HOUSING EXPENSES	Add Section C
E. TOTAL EXPENSES	Section B + C
F. TOTAL NET INCOME	Section A
G. INCOME – EXPENSES	Section F - E

ADDITIONAL PEOPLE IN HOUSE (IF NEEDED)
Person Name	Relationship to You?	Gender	Date of Birth	Veteran?	Disability?
ADDIITONAL INCOME IN HOUSE (IF NEEDED)
Employment Income
About	Job 1	Job 2	Job 3	Job 4
Employee Name
Job Title
Employer Name
Start Date
Type of Company
Hours per week
Monthly Pre Tax Income
Monthly Post Tax Income
Other Income (Social Security, rent, pension)
Person Receiving	Type of Income	Amount	Frequency
OTHER MORTGAGES AND OTHER LIENS ON YOUR PROPERTIES
Mortgage	Property/Mortgage 4	Property/Mortgage 5	Property/Mortgage 6
Property Address
Company Name
Loan Number
Payment
Interest Rate
Fixed or Adjustable Rate?
# Payments Behind
Amount Behind
Original Principal
Principal Remaining
Loan start date
Loan end date
FHA, VA, Fannie Mae, or Freddie Mac?
Heard from Foreclosure Attorney?	☐ Yes	☐ No	☐ Yes	☐ No	☐ Yes	☐ No
Sheriff’s Sale Date
Have you postponed your sale?	☐ Yes	☐ No	☐ Yes	☐ No	☐ Yes	☐ No
Last Refinance Date
Last Modification Date
Property Tax Yearly Amount?
Property Taxes Escrowed?	☐ Y	☐ N	☐ Y	☐ N	☐ Y	☐ N
Property Taxes Current?	☐ Y	☐ N	☐ Y	☐ N	☐ Y	☐ N
Homeowner’s Insurance Yearly Amount?
Homeowner’s Insurance Escrowed?	☐ Y	☐ N	☐ Y	☐ N	☐ Y	☐ N
Homeowner’s Insurance Current?	☐ Y	☐ N	☐ Y	☐ N	☐ Y	☐ N
Is the property in a Homeowners’ Association?	☐ Y	☐ N	☐ Y	☐ N	☐ Y	☐ N
Homeowner’s Association Dues Current?	☐ Y	☐ N	☐ Y	☐ N	☐ Y	☐ N
Homeowners’ Association Dues Monthly Amount:
Homeowners’ Association Dues Months Behind:

HECAT & HUD Privacy Act Notice

We at Twin Cities Habitat for Humanity value your trust and are committed to the responsible management, use and protection of personal information. This notice describes our policy regarding collection and disclosure of personal information. The following programs area funded in part by the Homeownership Education Counseling and Training (HECAT) Fund and United States Department of Housing and Urban Development (HUD): Homebuyer Education (Home Stretch & Pathways Home), Homebuyer Counseling, Home Equity Conversion Mortgage Counseling or Reverse Mortgage Counseling and Foreclosure Counseling. The HECAT funders include: Minnesota Housing, Minnesota Homeownership Center, Greater Minnesota Housing Fund, and the Family Housing Fund.

Social Security Numbers

The Privacy Act of 1974 makes it unlawful for any Federal, State, or local government agency to deny your participation in this Homebuyer Counseling program if you refuse to provide your social security number. If you do not provide your social security number services to you may be more limited, but you will continue to be eligible to receive services we can provide without a social security number.

Other Private Data

Under Minnesota Statutes, your name and address are public data. All other data we may ask about you is private data on individuals. Agreeing to share your public data is mandatory for participation in the HECAT funded programs listed above. Sharing your private data is not mandatory for participation in the program. However, if you do not provide private information (such as income, debts, and assets) services to you may be more limited.

We collect private information for the purposes of program management, compliance monitoring, research, and program evaluation to (check all that apply):

☐ Support homebuyer education

☐ Support homebuyer counseling

☐ Support reverse mortgage counseling

☒ Support foreclosure counseling

We collect your private information from the following sources: information that we receive from you on applications or other forms, information about your transactions with us, and information we receive from a consumer reporting agency.

We may disclose the following types of private information about you;

Information we receive from you on applications or other forms, such as your name, address, social security number, employer, assets, debts, and income;

Information about your transactions with us, and

Information we receive from a consumer credit reporting agency, such as credit bureau reports, your credit history and your creditworthiness.

We may disclose your private information to the following entities or their representatives identified above and to other entities properly authorized under law to review it.

Staff at this organization who need it to work on your case;

HECAT funders: Minnesota Housing Finance Agency, Family Housing Fund, Greater Minnesota Housing Fund, and the Homeownership Center;

United States Department of Housing and Urban Development (HUD).

I acknowledge that I have received this notice and understand and agree to its content. Please indicate your acknowledgement with your signature, below.

Client Name	Client Signature	Date
Client Name	Client Signature	Date

For counselor use only:
Verbal acknowledgement is acceptable if information was provided to client in non face-to-face counseling session.
The undersigned verifies that verbal acknowledgement has been given. The client was fully informed of the information contained herein and understood its nature.
Client Name	Counselor Signature	Date
NOTE TO COUNSELOR: We recommend sending a copy of the Combined Privacy Act Notice to clients who have given verbal acknowledgement of this notice. At a minimum, clients must provide public data (i.e. name and address) to receive HECAT services. If a client refuses to provide public data the Educator/Counselor may not provide HECAT services.

HECAT & HUD Conflict Warning and Disclosure

We are committed to ensuring 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 information shared both orally and in writing will be managed within the limitations of law. Please carefully read the following disclosures and acknowledgements.

I understand that Twin Cities Habitat for Humanity provides foreclosure mitigation counseling after which I will receive a written Action Plan consisting of recommendations for handling my finances, possibly including referrals to other housing agencies as appropriate.

I understand that Twin Cities Habitat for Humanity receives federal and state funding from the U.S. Department of Housing and Urban Development and the Minnesota Housing and Finance Agency and it is required to share some of my personal information with the entities as described and acknowledged in the “Combined Privacy Act Notice,” for the purposes of program monitoring, management, compliance, and evaluation.

I understand that a counselor may answer questions and provide information, but not give legal advice.

I understand that, in addition to foreclosure mitigation counseling, Twin Cities Habitat for Humanity also provides the following types of services:

Home purchase counseling, A Brush With Kindness home repair, Restore home improvement store.

I understand that Twin Cities Habitat for Humanity is required to fully disclose potential and actual conflicts of interest so that I am in a position to make fully informed decisions.

I understand that Twin Cities Habitat for Humanity or one of its foreclosure mitigation counselors may have one of the following conflicts through referral or in fact:

☐ We hold or service a mortgage secured against your property and have a stake in the performance of the loan;

☒ We purchases, redevelop, and sell, for a fee, properties at risk of, or involved in foreclosure;

☒ We receive financial support from mortgage servicer or investor. Payment may be based on acceptance of a loss mitigation offer.

I understand that I may be referred to other services of the organization or another agency or agencies as appropriate that may be able to assist with particular concerns that have been identified. I understand that I am not obligated to use any of the services offered to me.

I acknowledge that I have received a copy of the Privacy Act Notice and that if I choose to not sign or verbally acknowledge the Privacy Act Notice, my counselor may not provide foreclosure prevention counseling services.

I acknowledge that Twin Cities Habitat for Humanity and NeighborWorks America may conduct follow-up with me related to program evaluation.

I acknowledge that I have received this notice and understand and agree to its content. Please indicate your acknowledgement with your signature, below.

Client Name	Client Signature	Date
Client Name	Client Signature	Date

For counselor use only:
Verbal acknowledgement is acceptable if information was provided to client in non face-to-face counseling session.
The undersigned verifies that verbal acknowledgement has been given. The client was fully informed of the information contained herein and understood its nature.
Client Name	Counselor Signature	Date
NOTE TO COUNSELOR: We recommend sending a copy of the Combined Privacy Act Notice to clients who have given verbal acknowledgement of this notice. At a minimum, clients must provide public data (i.e. name and address) to receive HECAT services. If a client refuses to provide public data the Educator/Counselor may not provide HECAT services.