Mediation Intake Form

Homeowner #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

EMPLOYER NAME:

Family Size:

Number of Dependents:

Homeowner #2

Homeowner #2 Income/month

EMPLOYER NAME:

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

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Office Phone

217-423-0352

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Housing Counselor

217-423-4901

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Mail To

P.O. Box 228, Decatur, IL 62525

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