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SCHAP Intake Form
Name
This field is for validation purposes and should be left unchanged.
Owner(s) on Deed:
DOB:
MM slash DD slash YYYY
Owner(s) on Deed:
DOB:
MM slash DD slash YYYY
Owner(s) on Deed:
DOB:
MM slash DD slash YYYY
Client Phone Number:
Email:
Relationship to Home Owner:
(Tel):
Home Address:
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Mailing Address (if different from home / and why?):
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Why?:
Household Size:
# of Units:
Vacant Units:
Home Insurance:
Reverse Mortage:
Yes
No
Do you have access to $15,000 or more in assets?
Yes
No
How long have you owned your home?:
Estimated Property Value $:
Are you Disabled?:
Ethnicity:
Gross Monthly Income $:
Rental Income $:
Other Income $:
Current Mortgage Lender(s):
Current Mortgage Balance(s) $:
Current Interest Rate(s) %:
Current Monthly Mortgage Payment(s) $:
Mortgage in Arrears:
Yes
No
If yes, how many months:
Why?:
Other Debt(s) e.g Judgments, Utilities, Unsecured Credit (type and amount):
Water & Sewer Arrears:
Yes
No
Amount Owed $:
Do you have an Agreement:
Yes
No
Comments:
Real Estate Taxes Arrears:
Yes
No
Amount Owed $:
Do you have an Agreement:
Yes
No
Comments:
Repair / rehabilitation needs (describe briefly):
How did you hear about this program:
Referral Agency (if any):
Telephone:
Contact Person:
Telephone:
Additional Information:
How would you like to receive the application?
Mail
Email
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