CHN Homeownership & FinCap Intake Application

Page 1

Welcome! We look forward to working with you. 

Please complete this application in its entirety and provide all requested documentation. 

If you have questions or need assistance, please call 216.881.8443. 

Page 2

Applicant and Co-Applicant Details

In this section, please enter your most up to date contact information and demographic information.

CHN Housing Partners (CHN) is committed to assuring the privacy of individuals and/or families who have contacted us for assistance. We realize that the concerns you bring to us are highly personal in nature. We assure you that all personal information shared verbally and/or in writing will be managed within ethical and legal consideration. Additionally, we want you to understand how we use the personal information we collect. Please carefully review this notice as it describes our policy regarding the collection and disclosure of your nonpublic, personal information.
CHN's Privacy Policy

The Applicant (and Co-Applicant, if applicable) should be an adult member of your household that will be able to represent, provide information for, and make decisions on behalf of your household. 
Applicant Information

Enter date in MM/DD/YYYY format

Co-Applicant Information

Enter date in MM/DD/YYYY format

Page 3

Current Income Sources and Public Benefits

Please enter all sources of Income and Public Benefits that your household is CURRENTLY receiving, for all household members over the age of 18. 

Use the "Add Additional Income Source" link to add as many as you need

Current Annual Income is the estimated income for the current year including any wages,

benefits, alimony, child support and other forms of financial income or support.

Income includesFull-time employment, part-time employment, self-employment, spousal support, child support, investment income, Social security, SSI, SSDI, income from assets, pension/annuity, unemployment, adoption subsidy, short term disability, long term disability, veteran's benefits, zero income, family contribution, other

Public benefits include
Food stamps, WIC, ADC, OWF/TANF, rental subsidy, utility allowance, other public benefit

Current Income or Public Benefit Source

Enter the Household Member who this income belongs to

Provide the Job Title for Employment types, if applicable

Please take the total income you received in the last 30 days and multiply by 12 to determine your annual income:

Please estimate to the best of your ability. Our staff will review your documents and provide a full eligibility determination.

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Assets Declaration

If you are taking Homebuyer classes, or intend on applying for down payment assistance and/or first-time homebuyer programs, knowing your current assets helps us have a better understanding of what products and programs you may be eligible for. 

Please enter all liquid Assets you have control over for all household members over the age of 18. Liquid assets are cash on hand or assets in any other form that can be converted to cash within 20 days (

Asset types include: Bank Accounts - Savings and/or Checking, Investment Accounts, Retirement, Certificates of Deposit, Cash on Hand, Pre-paid Debit Cards, Health Savings Accounts, Life Insurance Cash Value


Please estimate to the best of your ability - enter 0 if unsure

Page 5

Credit Score and Credit Report

If you are not currently mortgage-ready, you will be referred to a Homeownership Coach for a financial coaching session. Part of this discussion will be a credit overview, including a review of your credit report and how it relates to your overall credit score. You will then be provided with tips on how to improve your credit score and reduce your debt.

To have a productive conversation about credit, we ask that you visit and provide us with a copy of your credit report(s).

Note: Federal law requires each of the three nationwide consumer credit reporting companies - Equifax, Experian and TransUnion - to give you a free credit report every 12 months if you ask for it. You can get a free report from each of the three nationwide consumer credit reporting companies through

Please go to and request your credit report(s). Make sure to download a PDF copy of each credit report you request and upload a copy of the report(s) here.

This is a secure file upload, your reports will be uploaded directly to our Salesforce portal.

There are many free tools available for credit monitoring, such as: Experian, Credit Karma, Credit Sesame, etc... If you use online banking, your bank may also offer credit monitoring for free. If you use one of these tools and have a copy of your credit score, please share below.

Your credit score should be a number between 300 and 850.

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Current Housing and Financial Information 

We will be asking more specific questions about your Housing and Financial Details here, including your living situation, goals, and financial information. This information will allow for us to screen eligibility for the wide range of programs we offer. You will be under no obligation to participate in programs we recommend.
Housing and Financial Information

Our team can provide the best information and guidance for your situation by understanding your financial goal and other financial details.

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Documentation is not required; however, the following items may be helpful to us as we work with you. 

If taking photos with your phone/camera, you can line up your IDs and Social Security cards within one image, instead of one at a time

Page 8

Housing Counseling Disclosure

About Us and Program Purpose: The mission of CHN Housing Partners (CHN) is to build strong families and vibrant neighborhoods through quality affordable housing and strengthened financial stability. CHN is a nonprofit, HUD-approved housing counseling agency. We provide free housing counseling and education services, including Mortgage Delinquency & Default Resolution, Reverse Mortgage, Pre-purchase, Financial, Budgeting, & Credit Repair, and Rental Housing Counseling services, as well as Financial, Budgeting, & Credit Repair and Pre-purchase Homebuyer Education Workshops. 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 anti-discrimination laws, including the federal Fair Housing Act (42 USC 3600, et seq.). 

Affirmatively Furthering Fair Housing
Everyone living in the United States is protected by fair housing laws. A person cannot be discriminated against in housing based on their membership in one or more protected classes.

To learn more about your rights, please visit Fair Housing: Know Your Rights.

As a housing counseling program participant, please affirm your roles and responsibilities along with the following disclosures and initial, sign, and date this form below.

Client and Counselor Roles and Responsibilities

Termination of Services: Failure to work cooperatively with your housing counselor and/or CHN will result in the discontinuation of counseling services. This includes, but is not limited to, missing three consecutive appointments. By signing below, you are acknowledging that you have read and understood this. 

Agency Conduct: No CHN employee, 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 Relationship: CHN has financial affiliation with HUD, United Way of Greater Cleveland, the State of Ohio, Cuyahoga County, the City of Cleveland, and banks including Third Federal, KeyBank, and JP Morgan Chase. As a housing counseling program participant, you are not obligated to use the products and services of CHN or our industry partners.  

Alternative Services, Programs, and Products & Client Freedom of Choice: In the interest of full disclosure, CHN also provides utility services with partnerships through: Dominion East Ohio, Illuminating Company, Cleveland Public Power, Division of Water, NEO Regional Sewer District, and U.S. Department of Energy, Health, and Human Services. CHN also provides tax preparation through a partnership with Enterprise Community Partners and the IRS VITA program. As a housing counseling client, you are not obligated to participate in any of these services. You are entitled to choose whatever services and/or products best meet your needs. 

Fees: CHN currently charges a fee of $125 for Reverse Mortgage Counseling, paid to CHN upon service. All other direct services are free of charge. Service cannot be denied due to an inability to pay and cannot impose a financial hardship. CHN also offers two online homebuyer education platforms, Framework and eHome America, which cost $75 and $99, respectively, and are paid directly to the vendor. If applicable, I/we acknowledge that you received a copy of CHN’s Fee Structure at the time Reverse Mortgage Services were provided. 

Referrals and Community Resources: CHN provides a community resource list which outlines regional services available to meet a variety of needs, including utility assistance, food banks, and legal aid assistance, among others. This list also identifies alternative agencies that provide services, programs, or products identical to those offered by CHN. 

Privacy Policy: I/we acknowledge that you received a copy of CHN’s Privacy Policy.

Home Inspection: If applicable, I/we acknowledge that you received a copy of ‘For Your Protection: Get a Home Inspection’ and ’10 Important Questions to Ask Your Home Inspector’. You can access these forms here: 
For Your Protection: Get a Home Inspection
10 Important Questions to Ask Your Home Inspector
Sample Home Inspection Checklist

Lead-Based Paint: I/we acknowledge that you received a copy of ‘Disclosure of Lead-Based Paint Hazards in Housing’ and ’Protect Your Family from Lead in the Home’. You can access these forms here:
Disclosure of Lead-based Paint Hazards in Housing
Protect Your Family from Lead in the Home

Errors and Omissions and Disclaimer of Liability: 
I/we agree that CHN, its employees, agents, and directors are not liable for any claims and causes of actions arising from errors or omissions by such parties, or related to my participation in CHN counseling; and I hereby release and waive all claims of action against CHN 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. If any provision of this document is unenforceable, it shall be modified to the extent necessary to make the provision valid and binding, and the remainder of this document shall remain enforceable to the full extent allowed by law. Please note that representatives of CHN do not provide tax or legal advice and that you should consult your tax advisor or attorney for such guidance.

Quality Assurance: In order to assess client satisfaction and in compliance with grant funding requirements, CHN, 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 your client experience. Your survey data may be confidentially shared with CHN grantors such as HUD.

Sharing of Information: By signing this Disclosure Statement I give CHN authorization to share my information with HUD and other third parties, as applicable.

Clients of Neighborhood Housing Services of Greater Cleveland, Inc.: In July of 2019, NHS of Greater Cleveland, Inc. became an affiliate of CHN and all housing counseling activities of both agencies are now administered and managed by CHN. If you were an active client of NHS of Greater Cleveland, Inc. before July 2019 we require your agreement to allow CHN employees to access your information across our integrated platform in the ways and for the purposes outlined above. You may receive this request from us even if you have a current authorization form on file with NHS of Greater Cleveland, Inc. 

Privacy Policy:

CHN Housing Partners CHN) is committed to assuring the privacy of individuals and/or families who have contacted us for assistance. We realize that the concerns you bring to us are highly personal in nature. We assure you that all personal information shared orally and/or in writing will be managed within ethical and legal consideration. Additionally, we want you to understand how we use the personal information we collect. Please carefully review this notice as it describes our policy regarding the collection and disclosure of your nonpublic, personal information.

 What is nonpublic, personal information?
  • Information that identifies an individual personally and is not otherwise publicly available information, such as your Social Security Number or demographic data such as your race and ethnicity
  • Includes personal financial information such as credit history, income, employment history, financial assets, bank account information and financial debts
What personal information does CHN collect about you and from what sources? 
  • Information that you provide on applications, forms, emails, or verbally 
  • Information about your transactions with us, our affiliates, or others 
  • Information we receive from your creditors or employment references
  • Credit report
What categories of information do we disclose and to whom? 
We may disclose the following personal information to financial service providers (such as companies providing home mortgages) Federal, State, and nonprofit partners for program review, monitoring auditing, research, and/or oversight purposes, and/or any other preauthorized individual and/or organization. The types of information we disclose are as follows: 
  • Information you provide on applications/forms or other forms of communication. This information may include your name, address, Social Security Number, employer, occupation, account numbers, assets, expenses, and income. 
  • Information about your transactions with us, our affiliates, or others; such as your account balance, monthly payment, payment history, and method of payment. 
  • Information we receive from a consumer credit reporting agency, such as bureau reports, your credit and payment history, your credit scores, and/or your creditworthiness. 
  • We do not sell or rent your personal information to any outside entity. 
  • We may share anonymous, aggregated case file information; but this information may not be disclosed in a manner that may personally identify you in any way. This is done in order to evaluate our program, gather valuable research information, and/or design future programs. 
  • We may also disclose personal information about you to third parties as permitted by law or when required by a governmental authority
How is your personal information secured? We restrict access to your nonpublic personal information to CHN employees who need to know that information in order to perform their housing counseling duties. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your nonpublic personal information; and we train our staff to safeguard client information and prevent unauthorized access, disclosure, or use.

Opting out of certain disclosures: You may direct CHN to not disclose your nonpublic, personal information to third partners (other than disclosures made to project partners, those permitted by law or required by governmental authorities). However, if you choose to opt out, we will not be able to answer any questions from your creditors, which may limit CHN’s ability to provide services such as foreclosure prevention counseling. If you choose to opt out, please call 216.881.8443 and advise that you wish to opt out of certain disclosures. 

Acknowledgement & Submit

I/we certify that all provided information is correct to the best of my knowledge and have received a copy of CHN's Housing Counseling Disclosure and Privacy Policy. I/we authorize CHN Housing Partners to verify all information contained on this online form and to pull my credit report. I/we understand that I may be assisted by federal funds which carry severe penalties, including incarceration.

By typing my full name below, I hereby authorize CHN to release nonpublic personal information it obtains about me to any third parties necessary to provide me with the services I requested. I acknowledge that I have read and understand the above privacy practices. I understand I will receive a copy of all information submitted at the email address I provided on Page 2, "Applicant E-mail Address".