Housing Counseling Intake Form

Today's Date MM/DD/YY*
Were you asked to complete this form? If so, by which staff person or what reason?*
First Name*
Last Name*
Address (Please include apt.)*
City*
State*
Zip Code*
Phone Number*
Email
Date of Birth MM/DD/YY*
Please list your gross monthly income for all household members. Please click the + to add additional income sources. This is required.*
Household Member (Name) Type of Income (Job, Food Stamps, SSI, Etc.) Gross Monthly Income (Before Taxes)
DEMOGRAPHIC INFORMATION: Demographic information is used solely for statistical reporting requirements
GENDER*
ETHNICITY*
RACE*
MARITAL STATUS*
Is English your preferred language?*
If English is not your preferred language, please list your preferred language below.
Highest Level of Education Completed?*
Total Number of Adults (18+) in the Household?*
Total Number of Children Ages 13-17?*
Total Number of Children Ages 12 and Younger?*
Is your household considered to be a Female-Headed household?*
How do you prefer to be contacted? Please note, you may select multiple options.*
Are there any accommodation needs that you have such as physical, print, or language barriers? If yes, please describe.
Did anyone refer you? If yes, who?
Please check below if you understand that our NEW OFFICE SPACE is located at 2393 Main St. Buffalo, NY 14214.*
- __I understand
Consent*
By clicking this box, you are agreeing that you have been made aware of these services and financial relationships. This checkbox will serve as your electronic signature.
Housing Counseling is provided free of charge. Belmont Housing Resources for WNY does not charge for any counseling services and no money or gifts should ever be exchanged for services provided. The program is intended to educate families and individuals on housing related opportunities. The goal of the housing counselors is to educate and communicate to the community affordable housing opportunities, lending products and other forms of assistance that may be available to them. Counselors may also assist in the facilitation of obtaining such opportunities if desired by the client. Clients are under no obligation to utilize these programs or services. We are able to provide our services free of charge due to the financial support of the entities listed below. Your counselor receives a salary and does not receive any extra financial compensation for referring you to a specific program. They will inform you if we are being reimbursed specifically for the cost of your counseling. Funding sources including HUD and Project Reinvest may require Belmont to share some of your demographic and housing information with program officials for purposes of program monitoring and compliance.
Financial support for our services comes from a variety of sources which may include:
*US Departments of Housing and Urban Development and Health and Human Services *Federal Home Loan Bank of New York and Cincinnati *New York State Homes and Community Renewal (HCR)* NYS Attorney General *County of Erie *Cities of Buffalo and North Tonawanda *Towns of Amherst, Cheektowaga, Hamburg, and Tonawanda *Bank of America Foundation *Citizens Bank *KeyBank Foundation *M&T Foundation *Local Initiative Support Corporation *Westminster Foundation *United Way of Buffalo and Erie County *National Community Capital*
It is a conflict of interest for any employee, volunteer or agent of Belmont to accept a fee or any consideration for personal or private gain for referring clients to any funder, individual or entity with a financial interest.
Belmont Housing Resources for WNY, Inc. is a diverse housing agency providing a variety of programs. You are under no obligation to utilize any of these programs, Belmont will provide information (attached) on alternative services, programs and products. Programs provided by Belmont include:
Housing and Financial Management Counseling & Education*First-Time Homebuyer*Financial Counseling & Coaching*Post-Purchase*Foreclosure Prevention*Reverse Mortgage (HECM)*Rental/Homeless Prevention*Housing Choice Voucher (HCV) Program*Rental assistance*Family Self-Sufficiency*HCV Homeownership*Family Unification Program*Mainstreaming People with Disabilities Program*Veterans Administration Supportive Housing Programs*Housing Development*First-time homebuyer programs*Owner-occupied rehabilitation loan programs*Acquisition/rehab/resale programs*Property Management*Management of Affordable Rental Housing
Phone
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Housing Counseling Intake Form

DEMOGRAPHIC INFORMATION: Demographic information is used solely for statistical reporting requirements

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Niagara County Office

Thank you to The Western New York Foundation for their generosity and support.

Household Member (Name)	Type of Income (Job, Food Stamps, SSI, Etc.)	Gross Monthly Income (Before Taxes)