SCHAP Intake Form 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 EmailThis field is for validation purposes and should be left unchanged. Δ
