Application

Intake Form Application

Step 1 of 5

Name(Required)

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Email(Required)

Date of Birth(Required)

Home Phone

Cell Phone(Required)

Consent(Required)

I agree to the terms.

I understand that SMILE Community Action Agency provides foreclosure mitigation counseling and housing 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 there is a fee of $24.90 for my credit report. If I am at risk for closure, there is no charge for counseling. If my household income is below 50% of the Area Median Income there is no charge for counseling.

I may be referred to other housing 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.

A counselor may answer questions and provide information, but not give legal advice. If I/we want legal advice, I will be referred for appropriate assistance.

I understand that SMILE counselors may discuss information about my/our credit history, financial situation, employment, or other family problems. I authorize SMILE to release Credit, financial, employment, and other information to other agencies or firms as may be essential to the solving of our housing problem.

I understand that smile may refer me to lenders I may understand that smile may refer me to lenders so that I may submit an appropriate loan understand that SMILE may refer me to lenders so that I may submit an appropriate loan application, where applicable. I hereby explicitly give lenders or potential lenders permission to share my application with SMILE for the reporting purposes hereby waiving any prohibition of such disclosure under GLBA privacy provisions and regulation P of the Code of Federal Regulations.

I understand that if any information provided by me is found to be falsified, legal action can and will be taken against me.

I understand by signing this document that I am not guaranteed assistance.

Consent(Required)

I agree to the privacy policy.

SMILE Community action agency is committed to ensuring the privacy of individuals and/or families with contact us for assistance. We realize that the concerns you bring to us or Harley are personal in nature. We are sure you got all the information shared both orally and in writing will be managed within legal and ethical considerations. Your “non-public personal information”, such as your total information, income, living expenses, and personal information concerning your financial circumstances, will be provided to creditors, program monitors, and others only with your authorization and signature on the Client Counseling Authorization Form. We may also use anonymous aggregated case file information for the purpose of evaluating our services, gathering value will research information, and designing future programs.

Types of information that we gather about you:
* Information we received from you orally, on applications or other forms, such as your name, address, Social Security number, assets, and income
* Information about your transactions with us, your creditors, or others, such as your account balance, payment history, parties to transaction, and credit card usage;
* Information we received from a credit-reporting agency, such as your credit history
You may opt-out of certain disclosures
* You have the opportunity to opt-out of disclosures of your non-public personal information to third parties (such as your creditors), that is, direct us not to make those disclosures.
* If you choose to “opt-out”, we will not be able to answer questions from your creditors. If is anytime you wish to change your decision with regard to your opt-out, you may call or email us.
Release of your information to third parties
* So long as you have not opted out, we may disclose some or all of the information that we collect, as described above, to your creditors or third parties where we have determined that it would be helpful to you, would eat us in counseling you, or is the requirement of grant awards which make our services possible.
* We may also disclose any non-public personal information about you or former customers to anyone as permitted by law (for example, if we are compelled by legal process).
* Within the organization, we restrict access to non-public personal information about you to those employees who need to know that information to provide services to you. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your non-public personal information.

Disclosure Form(Required)

I agree to the disclosure form.

SMILE Community Action Agency is pleased that you have come to us for services. We are looking forward to
working with you. Please note that we are here to assist you in resolving your housing issues. However, you
may use services other than those provided by this agency. Generally, your services may include the
following:
• The gathering of essential demographic and financial information to resolve your housing need.
• An assessment of your housing situation.
• A case management plan that provides instructions and identifies resources for resolving housing
needs.
• Individual face-to-face, telephone, and/or group counseling designed to guide you through the
process of resolving housing needs.
• Follow-up calls and/or letters to track the outcome of our services:
1) Pre-purchase Counseling= Preparing for Home Purchase;
2) Pre-purchase Homebuyer Education Workshops= Online classes;
3) Fair Housing Pre-Purchase Education Workshops= Group;
4) Mortgage Delinquency and Default Resolution Counseling= Mortgage Assistance;
5) Non-Delinquency Post Purchase Workshops= After Purchase Counsel;
6) Financial Management/Budget Counseling= Budgeting; and
7) Financial, Budgeting, and Credit Workshops= Credit Repair.
SMILE Community Action Agency upholds the highest standards of customer service. As such, SMILE staff
members providing these services will adhere to the following guidelines:
• SMILE does not offer legal counsel or services. SMILE staff members will provide counseling, group
education, and/or instructional information only regarding your housing, personal financial
management, or credit situation under this program.
• SMILE does not provide debt consolidation services nor will any SMILE staff member take over or assume
responsibility for finances of any participating client.
• SMILE does not pay or receive fees or other considerations for referrals to or from any program
administered by us.
• SMILE staff members will not recommend that clients participate or engage in any services whereby
the staff members themselves or any member of their immediate family have a financial interest.
• SMILE staff members will not disclose any personal information without proper authorization from the
participant.
• SMILE strongly believes in and promotes housing choice. To that end, SMILE will not endorse any realtor
or lender.
Participants in SMILE’s Pre-purchase Counseling Program shop for and select the vendors that best suit their
needs.
SMILE, in many instances, will need to pull your credit report in order to assess the condition of your credit
either to determine your readiness for ownership or to assist in the resolution of the mortgage delinquency.
SMILE has the ability to pull your credit with little to no effect on your credit score.
SMILE employs individuals who are qualified to provide the services rendered. To that end, all SMILE housing
counselors are required to be certified. New counselors employed by SMILE have one year to acquire such
certification, which can be obtained through the Association of Housing Counselor, the National Federation of
Housing Counselors or Neighbor Works. Central SMILE’s mission is the elimination of housing discrimination. All
of SMILE’s programs and services are required to educate participants.
Please be advised that you, the client, are not obligated to receive, purchase or utilize any other services
offered by SMILE, or its exclusive partners, in order to receive housing counseling services.
This certifies that I have read and understand the above statement of disclosure.

Signature(Required)