SCHAP Intake Form Owner(s) on Deed: DOB: Owner(s) on Deed: DOB: Owner(s) on Deed: DOB: 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 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: Name This field is for validation purposes and should be left unchanged.