HomeHousing CounselingTriageMediation Intake Mediation Intake Form PhoneHomeowner #1 Information Name: Street Address: Cell phone number: Maiden name: City, State, Zip Home phone number: U.S. Citizen: Yes No Email SSN (Last 4 digits): Date of birth: Homeowner #2 Information Name: Street Address: Cell phone number: Maiden name: City, State, Zip Home phone number: U.S. Citizen: Yes No Email SSN (Last 4 digits): Date of birth: Household Expense Utilities paid/month: Medical Insurance premiums/month Groceries cost/month Prescription Medication cost/month Child Support paid/month: Child Care paid/month Car payments/month Homeowner #1 Homeowner #1 Income/month Income Type: Disability SSI Salary (hourly) Pension Military Child Support EMPLOYER NAME: Homeowner #1 Demographic Information Race: White Asian/Pacific Islander African-American Bi-Racial Ethnicity: Hispanic Native American Other Non-Hispanic Gender: Female Male Transgender Other Marital Status: Single Divorced Married Civil Union Widow Separated Current Living Situation: Rent Own/Purchasing Home Homeless Shelter Living with others Mobile Home Nursing Home/Assisted Living Other Disabled? Yes No Veteran? Yes No Family Member Veteran? Yes No Highest Level of Education: High School Diploma Bachelor's Degree Master's Degree Family Size: Number of Dependents: Homeowner #2 Homeowner #2 Income/month Income Type: Disability SSI Salary (hourly) Pension Military Child Support EMPLOYER NAME: Homeowner #2 Demographic Information Race: White Asian/Pacific Islander African-American Bi-Racial Ethnicity: Hispanic Native American Other Non-Hispanic Gender: Female Male Transgender Other Marital Status: Single Divorced Married Civil Union Widow Separated Current Living Situation: Rent Own/Purchasing Home Homeless Shelter Living with others Mobile Home Nursing Home/Assisted Living Other Disabled? Yes No Veteran? Yes No Family Member Veteran? Yes No Highest Level of Education: High School Diploma Bachelor's Degree Master's Degree Homeowner Mortgage Property Information Mortgage Amount each month: Date of last mortgage payment made: Taxes/Insurance included? Yes No Reason for Delinquency:We are to provide ethnicity/race data to US Department of Housing and Urban Development as part of their standards. If you decline to provide the data, staff will be required to provide the missing information by observer identification. Contact Us Office Phone217-423-0352 Housing Counselor217-423-4901 Mail ToP.O. Box 228, Decatur, IL 62525 FacebookLike Us! Twitter First Name * Last Name * Email Address * Phone Number Comments / Questions *
