Home Housing Counseling Triage Mediation Intake Triage Form Email Date of Application: Person Completing Form: Working with any other foreclosure counseling organization Yes No Name of Organization: Preferred Language? English Spanish Homeowner Information Name(s): Street Address: City: State: Zip Code Own Home as Primary Residence? Yes No Rental Property On the mortgage? Yes No Don't know Delinquent? Current Delinquent In Bankruptcy? Yes No Home Phone Cell Phone Other Phone Email Commitment Want to stay in Home? Yes No Monthly Income (Gross) Previous Delinquencies? Yes No When? Previous Workouts? Yes No When? Talked to Mortgage Company? Yes No Outcome: Money Available? Affordability First Mortgage Payment PITI? Yes No Mortgage Company: Delinquent: Yes No Second Mortgage Payment Mortgage Company: Delinquent: Yes No Months Delinquent: Third Mortgage Payment Mortgage Company: Delinquent: Yes No Months Delinquent: Delinquent Notices from attorney or court? Type: Mediation scheduled? Date: Reason for Default? Response date: Foreclosure sale scheduled? Date: RFD Resolved? Yes No Current Anticipated Date of Delinquency: Reason payment is or will be unaffordable? Interest Rate Reset Unemployment Reduced Income Other If other, please describe: Action Taken: FOR COUNSELOR USE ONLY Triage Outcomes Level 1: Referral info 2: Appt Immediately 3: Appt Soon 4: Appt Default 5: Appt Current 6: Transition Action Taken Provided or Sent Referral Info Sent Intake Packet Sent Workshop Schedule Registered for Workshop Scheduled Fl Appt Sent Transition Packet Scheduled Transition Appt Other If other, please describe Contact Us Office Phone 217-423-0352 Housing Counselor 217-423-4901 Mail To P.O. Box 228, Decatur, IL 62525 Facebook Like Us! Order Number First Name * Last Name * Email Address * Phone Number Comments / Questions *
