Tel. 719-263-5168 Fax 719-263-5460 www.totalconcept.net 34385 Hwy 167 PO Box 87 Fowler, CO 81039 PERSONAL PROFILE INTAKE FORM ERVICES EAN First time Homebuyer 2, Homebuyer Education 3. Pre-purchase Counseling Rental Counseling Home Repairs Down Payment Assistance Loan Modification Foreclosure Couriseling ‘nancial Counseling/Budgeting ss a a a ha lho Cedar sf el ote *" Quehlo bo goo4 a Deo Phone (719 ) ASA 3AS) ont fue ciser% g mail om Social Secwray Number 3 23_ 5574 Birthdate Aiea. 7 Frequen Frequency: pas rece ot Race: (Ciel) GRA tian American, Hispanic, Asian, American Indian, Other, choose CreditCards _$ /SD $1300 eat areal Veteran: Yes, Noe r Not College) Grad Schoo, Jr CaTlegs Jt High, None, cy, Vocational ———— ——— Ee First Time Home Buyer: Yes__No Marital Status: Maried Singh Set ge “ gg ©Client Services Disclosure Statement, Release of Information and Disclaimer of Liability, Credit Pull Authorization Total Concept: A Housing & Community Development Corporation offers housing counseling, financial counseling. and default morigage counseling. TCHCDC also renovates affordable housing. 1 acknowledge that I have been informed of the agency’s activities. All participants in TCHCDC’s programs are free to make their own choice of services and companies that can assist with the home purchase process. Participants are not obligated to receive, purchase, or utilize any other services offered by TCHCDC in order to receive Housing Coaching Services. Uhave read the above disclosure and understand and confirm my freedom of choice. { agree to release any information pertaining to my application with Total Concept to include bank statements, loan documents, paystubs, and any other documents that may be needed to complete my file. I understand that Total Concept is not a legal representative and that they will not be representing me in any capacity other than as a financial coach providing general information. | understand that foreclosure financing and home buying are legal transactions and proceedings, and that I should hire an attomey to receive legal advice and/or representation { authorize Total Concept to pull my credit for informational inquiry purposes. | understand that any intentional or negligent representation 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 Applicant Pine Nauline feiser as B//2S Signature: ee 88: _S¥3-03-5577 Co-Applicant Printed Name: Date: Signature: AUTHORIZATION TO COMMUNICATE VIA EMAIL (OPTIONAL) +L authorize Total Concept to send disclosures, notices, and other needed documents as well as communicate with me using electronic mail (email). Lunderstand that email may not be secure, and there is a risk of the email being read by a third party. * Total Concept will not be held responsible for any unauthorized access to my protected information while in transmission to me via email. +I may evoke this authorization at any time in writing to Total Concept BPW rope _ aofeas ‘Applicant Signature Date See ete ue a © &Errors and Omissions and Disclaimer of lity: I/we agree Total Concept HCA, 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 Total Concept HCA counseling; and | hereby release and waive all claims of action against Total Concept HCA and its affiliates. | have read this document, understand that | 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 and in compliance with grant funding requirements, Total Concept HCA, or one of its partners, may contact you during or after the completion of your housing counseling service. You may be requested to complete a survey asking you to evaluate your client experience. Your survey data may be confidentially shared with Total Concept HCA grantors such as HUD or NeighborWorks America I/we acknowledge that I/we received, reviewed, and agree to Total Concept HCA’s Program _ Disclosyres. lous Herds HM Lrsee 223 Name 1 Signature Date Counselor Signature Date Name 2 Signature Date