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Intake Form
Intake Form
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UnityPress Club
newsletter.
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Your Name
*
Spouse/Partner Name
Home Address (Number, Street, City, State, Zip)
*
Best Email Address
*
Best Phone Number
*
You You Retirement
Family Size
Selected Value:
1
Marital Status
*
Single
Married
Divorced
Separated
Civil Union
Widowed
Date of Birth
*
Number of Children Under 18
Selected Value:
0
If You Have Children Under 18, What Are Their Ages?
Are You (or Your Spouse/Partner) Foreign Born?
*
No
Yes
Are You (or Your Spouse/Partner) A Veteran?
*
No
Yes
Are You (or Your Spouse/Partner) Active Duty?
*
No
Yes
Preferred Language Spoken At Home?
*
English
Spanish
Arabic
Italian
Chinese
Farsi
Vietnamese
Korean
Tagalog
Swahili
French
Other
Are You Head of Household?
*
Yes
No
Are You Female Head of Household?
*
No
Yes
Are You Currently A Student?
*
No
Yes
If So, What School?
Are You A 1st Time Home Buyer? (Haven't Owned A Home In The Last 3 Years)
*
Yes
No
Are You A First Generation Home Buyer?
*
Yes
No
Have You Owned A Home In The Past?
*
No
Yes
Highest Household Education Level
*
High School Diploma/GED
Some College
College Graduate
Master's Degree
Doctorate
Vocational
Other
Do You or Someone In Your Household Have A Disability?
*
No
Yes
If Yes, What Services Are Required?
Household Description
*
Single Adult
Single Parent Household
Married With Children
Married Without Children
Related Adults
Unrelated Adults
Other
Total Household Income (Gross)
*
Employment Type
*
Full Time
Part Time
Self-Employed
Student
Unemployed
Spouse/Partner Employment Type (If Applicable)
Full Time
Part Time
Self-Employed
Student
Unemployed
Race (Check All That Apply)
*
Black/African-American
Hispanic
Native American
Asian
White
Other
I Do Not Wish To Furnish This Information
Ethnicity (Check All That Apply)
*
Black/African-American
Hispanic
Puerto Rican
Native American
Asian
White
Other
I Do Not Wish To Furnish This Information
Sex
*
Male
Female
Spouse/Partner's Sex (If Applicable)
N/A
Female
Male
Have You Pulled Your Credit Report/Scores In The Last 3 Months?
*
Yes
No
If Yes, What Were Your Scores? Any Collections, Lates, Etc.?
Estimated Bank Balances
*
Under $1,000
Under $5,000
Under $10,000
$10,000+
Estimated Retirement Account Balances
*
Under $1,000
Under $5,000
Under $10,000
$10,000+
How Did You Hear About Homeowner Prep?
*
When Is The Best Day(s)/Time(s) To Reach Out?
*
Submit
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