Foreclosure & Eviction Prevention Form

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Foreclosure Prevention

Applicant Information
Applicant Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Name of Apartment Complex (If Applicable)
Social Security Number*
Sex*
- Male
- Female
- Non-conforming
Marital Status*
- Single
- Engaged
- Married
- Divorced
- Widowed
Race / National Origin*
- American Indian / Alaskan
- African American / Black
- Asian American
- White
Ethnicity*
- Hispanic / Latino
- Not Hispanic / Latino
Are you a:
- Active Military
- Veteran
- Disabled
Age*
Date of Birth*
Household Size*
Number of Adults*
Number of Children*
Home Phone*
Cell Phone
Work Phone
Email*
Enter Email Confirm Email
How Did You Hear about Us?*
Co-Applicant Information
Co-Applicant Name
First Middle Last
Address (If same as above, list "Same")
Street Address Address Line 2 City State ZIP Code
Social Security Number
Sex
- Male
- Female
- Non-Conforming
Marital Status
- Single
- Engaged
- Married
- Divorced
- Widowed
Race / National Origin
- American Indian / Alaskan
- African American
- Asian American
- White
Military
- Active
- Veteran
- Disabled
Age
Date of Birth
Home Phone
Cell Phone
Work Phone
Email
Enter Email Confirm Email
How Did You Hear About us?
Mortgage Information
Monthly Mortgage Payment*
Are tax and insurance included in mortgage payment
- Yes
- No
Are you behind on your mortgage?*
- Yes
- No
If yes, by how many months.
Have you received any correspondence from an attorney or court concerning your mortgage?
- Yes
- No
Is there a sheriff sale scheduled for your home?
- Yes
- No
- I'm not sure
Are you working with an attorney regarding your mortgage.
- Yes
- No
Have you filed for bankruptcy regarding your mortgage?
- Yes
- No
How long at present address?*
Exp Date:*
Date Format: MM slash DD slash YYYY
Applicant Employment Information
Name of Applicants Employer*
Gross Annual Income*
Applicants title*
Date of employment*
Date Format: MM slash DD slash YYYY
Co-Applicant Employment Information
Co-Applicants Employer
Gross Annual Income
Co-Applicant Title
Co-Applicants Date of Employment
Date Format: MM slash DD slash YYYY
Other Household Income
Source of other income
Other Household Income
Source of other income
Other Household Income
Total Annual Gross Household Income*
Other Household Member Information
Other Household Members
First Last
Relationship to Applicant
Annual Income for other household member
Other Household Members
First Last
Relationship to Applicant
Annual Income for other household member
Other Household Members
First Last
Relationship to Applicant
Annual Income for other household member
Other Household Members
First Last
Relationship to Applicant
Annual Income for other household member
Other Household Members
First Last
Relationship to Applicant
Annual Income for other household member
Consent*
I agree to the privacy policy.
Tampa Bay Community Development Corporation – Disclosure Form
NOTE: If you have an impairment, disability, language barrier, or otherwise require an alternative means of completing this form or
accessing information about housing counseling, please talk to your housing counselor about arranging alternative accommodations.
About Us and Program Purpose: Tampa Bay Community Development Corporation (Tampa Bay CDC) is a nonprofit, HUD -
approved housing counseling agency. We provide education workshops and a full spectrum of housing counseling services
including pre-purchase, financial management, budget, credit repair, foreclosure prevention and non-delinquency post-purchase
counseling. TBCDC, in partnership with Community Service Foundation, builds, rents and sells affordable housing. We serve all
clients regardless of income, race, color, religion/creed, sex, national origin, age, family status, disability, or sexual
orientation/gender identity. We administer our programs in conformity with local, state, and federal antidiscrimination laws,
including the federal Fair Housing Act (42 USC 3600, et seq.). As a housing counseling program participant, please affirm your
roles and responsibilities along with the following disclosures and initial, sign, and date the form on the following page.

Counselor’s Roles and Responsibilities:
• Reviewing your housing goal and
your finances; which include your
income, debts, assets, and credit
history.
• Preparing a Client Action Plan that
lists the steps that you and your
counselor will take in order to
achieve your housing goal.
• Preparing your household budget
that will help you manage your
debt, expenses, and savings.
• Your Counselor is not responsible
for achieving your housing goal,
but will provide guidance and
education in support of your goal.
• Neither your counselor, nor Tampa
Bay CDC employees, agents, or
directors may provide legal advice

Client's Role and Responsibilities:
• Completing the steps assigned to you in
your Client Action Plan.
• Providing accurate information about your
income debts, expenses, credit, and
employment.
• Attending meetings, returning calls,
providing requested paperwork in a timely
manner.
• Notifying Tampa Bay CDC or your
counselor when changing housing goals.
• Attending education workshop (i.e. prepurchase
counseling workshop) as
recommended.
• Retaining an attorney if seeking legal advice
and/ or representation in matters such as
foreclosure or bankruptcy protection.
Termination of services: Failure to work cooperatively with your counselor and/ or Tampa Bay CDC will result in the
discontinuation of counseling services. This includes but is not limited to, missing three consecutive appointments.
Agency Conduct: No Tampa Bay CDC employee, officer, director, contractor, volunteer, or agent shall undertake any action
that might result in, or create the appearance of, administering counseling operations for personal or private gain, provide
preferential treatment for any person or organization, or engage in conduct that will compromise our agency’s compliance with
federal regulations and our commitment to serving the best interests of our clients.
Agency Relationships: Tampa Bay CDC has a financial affiliation with HUD, Neighborworks America, Florida Housing
Finance Corporation, Pinellas County, Pasco County, The City of Clearwater, The City of Largo, The City of St.Petersburg, and
banks including but not limited to Bank of America, Wells Fargo. I agree that Tampa Bay CDC may release information about
my membership, to the proper officials, in compliance with these contracts.
Alternative Services, Programs, and Products & Client Freedom of Choice: You are not obligated to participate or use any
programs and/ or services while you are receiving housing counseling from our agency. Your participation in a Tampa Bay CDC
program does not obligate or require you to use any series or products that may be suggested, offered, or recommended by
Tampa Bay CDC. You are entitled to choose whatever real estate professionals, lenders, and lending products that best meet your
needs.
Referrals and Community Resources: If asked for you will be provided a community resource list which outlines the county
and regional services available to meet a variety of needs, including utilities assistance, emergency shelter, transitional housing,
food bank, and legal aid assistance. This list also identifies alternative agencies that provide services, programs, or products
identical to those offered by Tampa Bay CDC and its exclusive partners and affiliates.
Privacy Policy: I/ We acknowledge that I/ We received a copy of Tampa Bay CDC’s Privacy Policy.
Errors, Omissions and Disclaimer of Liability: I/We agree Tampa Bay CDC, its employees, agents and directors are not liable
for any claims and causes of action arising from errors or omissions by such parties, or related to my participation in Tampa Bay
CDC counseling, and I hereby release and waive all claims of action against Tampa Bay CDC and its affiliates. I have read this
document, understand that I have given up substantial rights by signing it, and have signed it freely and without any inducement
or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by
law.
Quality Assurance: In order to asses client satisfaction and in compliance with grant funding requirements, Tampa Bay CDC, or
one of its partners may contact you during or after the completion of your housing counseling service. You may be requested to
complete a survey asking you to evaluate you client experience. You survey data may be confidentially shared with Tampa Bay
CDC’s grantors such as HUD OR Neigborworks America.
Authorization to Release Information: I/we hereby authorize Tampa Bay CDC to obtain all information necessary, including a
credit report, to assist me/us in an evaluation of our capacity to successfully accomplish, or maintain homeownership I authorize
TAMPA BAY COMMUNITY DEVELOPMENT CORP. I understand that depending on the type of service received, the
information may be shared with realtors and/or lenders in an effort to determine eligibility for mortgage financing, and develop a
plan to correct qualification deficiencies in the pursuit of a mortgage approval. I/we further authorize our first mortgage lender
Closing Title Company and/or realtor to provide Tampa Bay CDC with copies of any documents from my/our mortgage or real
estate file that would assist Tampa Bay CDC in the completion of my file.
Home Inspection Materials: (Home Buyer Education and/ or Pre-Purchase Counseling Only). By signing below I/ We certify
that I/ We received the following materials: “For Your Protection Get a Home Inspection” and “Ten Important Questions to Ask
a Home Inspector” Unless seeking services other than Home Buyer Education or Pre-Purchase counseling in which case these
materials are not applicable.
By Signing below, I/ We acknowledge that I/We received, reviewed and agree to
Tampa Bay CDC’s Program Disclosures as provided herein.
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Foreclosure & Eviction Prevention Form

Foreclosure Prevention

Applicant Information

Co-Applicant Information

Mortgage Information

Applicant Employment Information

Co-Applicant Employment Information

Other Household Income

Other Household Member Information

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Foreclosure Prevention

Applicant Information

Co-Applicant Information

Mortgage Information

Applicant Employment Information

Co-Applicant Employment Information

Other Household Income

Other Household Member Information

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