Please look over the form and gather any necessary information before filling the form out. Thank you!

Main Contact
Please provide the name and phone number of the person to contact if we have questions about your application. Thank you.
Participant 1Participant 2
Name (First, MI, Last)
Current Street Address
City, State
Zip Code
Home Phone
Work or Cell Phone
E-mail Address
Length of Employment
If less than 2 years, previous employment
Number of dependents and age(s)
Participant 1Participant 2
Wages (Before Deductions)
Child Support
Public Assistance
Total Income
Participant 1Participant 2
Savings Account(s)
Retirement Account(s)
Participant 1
Date of Birth
E.g., Jun 17 2024
Participant 2
Date of Birth
E.g., Jun 17 2024
Other Information
Reverse Mortgage or Mortgage Delinquency Counseling
First MortgageSecond Mortgage
Mortgage Company
How long have you had this mortgage?
Account Number
How many months behind are you?
Interest Rate
Authorization and Disclosures

Woodbine Community Organization (WCO) is authorized to obtain my credit report. In the event credit information is submitted to a mortgage company or other non-profit counseling agency, the undersigned authorizes that party to view and evaluate all credit information provided by the undersigned or WCO. I agree to have an employee of the Woodbine Community Organization (WCO) make or receive copies of all pertinent documents in regard to my housing situation for the purpose of mortgage default counseling. I hereby give WCO permission to discuss my financial situation, income, employment, details of my mortgage, and mortgage payment history with a representative of my mortgage company. I understand that WCO may from time to tome develop, own, sell, and rent property. I am under no obligation to avail myself to these services. I also understand that I am free to choose the realtor, home inspector, lending products, lender and home of my choice. The information I have provided to the WCO Housing Counseling Application does not represent a mortgage application. The information gathered is for the sole purpose of evaluation and counseling.
Occupancy affidavit: I affirm that I occupy the house at the address listed in this intake application and that that house is my primary residence.
Right to terminate counseling: I understand that WCO reserves the right to terminate a client from counseling if the client does not follow through with their action plan and remain in contact with their housing counselor.

Date (Participant 1)
E.g., Jun 17 2024
Date (Participant 2)
E.g., Jun 17 2024

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