MHHD Online Intake | Mercy Housing and Human Development

Mercy Housing requires EVERY client to submit an Intake upon request of Services. Please complete all required fields AND please specify what service you are requesting.

(NO FUNDING)

MHHD Rental Assistance

Date

Requested service

Contact Info

First Name

Last Name

Partner First Name

Partner Last Name

Home/Cell Phone Number

Street Address

City, State

ZIP Code

Housing

Do you live in a rural area?

How long at current address?

If less than 2 years, previous address

Currently rent, own, or live with family/friend?

Have you owned a home within the past 3 years?

Have you ever been evicted?

If yes, reason and date

Household Information

Race

Hispanic?

English Proficiency?

Number of people in household

Number of dependents in household

Any disabled family member(s)?

Applicant Information

Date of Birth

Gender

Marital status

Highest Level of Education

Are you a Veteran?

Date discharged

Have you ever been convicted of a crime?

If yes, reason and date

Partner Information

Date of Birth

Gender

Employment (Applicant)

Occupation

Place of employment

Length of employment

Gross monthly income

Employment (Partner)

Spouse/Partner occupation

Spouse/Partner place of employment

Spouse/Partner length of employment

Spouse/Partner gross monthly income

Financial Information

Household Gross Monthly Income

Household Gross Annual Income

Are you in the FSS Program?

Ever filed bankruptcy?

Do you have a Section 8 Voucher?

If yes, what is the amount?

Do you have funds set aside for security deposits?

If yes, how much?

Do you have a checking account?

Do you have a savings account?

Do you have an emergency fund?

Are you about to be or currently being evicted?

Would your current landlord give you a good or bad referral?

How did you hear about us? Referred by (if applicable)

MHHD Client Agreement Part One

I understand that: (a) Mercy Housing & Human Development (MHHD) is a HUD approved agency that provides confidential pre-purchase, post-purchase, foreclosure prevention, rental and credit counseling, after which I will receive a written Action Plan consisting of recommendations for handling my finances, possibly including referrals to other housing agencies as appropriate. (b) A counselor may answer questions and provide information about bankruptcy, but not give legal advice. (c) MHHD provides information and education on numerous loan products and housing programs and I further understand that the housing counseling I receive from MHHD in no way obligates me to choose any of these particular loan products or housing programs. (d) MHHD serves 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.).

I release, discharge, hold harmless, and forever acquit Mercy Housing & Human Development, Inc. and each and all of its employees, volunteers, agents, representatives, affiliates, successors, attorneys, and any and all other persons, or entities (including the Mississippi Home Corporation) who may in any manner be liable, therefore without limitation from: (a) any and all actions, claims, demands and causes of action, for any and all types, kinds or character of damages which any of us may now or hereafter have, on account of any credit, home ownership and home buying counseling or advice (b) any claims of any kind or nature made by any person or entity or corporation, including without limitation, any claims by the Internal Revenue Service and the Mississippi State Tax Commission regarding the aforementioned counseling, advice, work performed or otherwise (c) any and all claims or allegations of personal or injury, property loss, or damages occurring on the premises (d) any claims and causes of action arising from errors or omissions related to my participation in MHHD counseling

I agree to: (a) Arrive for my appointments on time or call in advance to cancel them (b) Provide accurate information about your income, debts, expenses, credit, and employment (c) Return requested paperwork in a timely manner (d) Contribute to the counseling sessions and follow through with my agreed upon action plans (e) Notify my counselor of any changes, including but not limited to contact information or goals (f) Be terminated from the program for non-compliance

MHHD Client Agreement Part Two

I authorize Mercy Housing & Human Development, Inc to: (a) use my name in any current and future publications or reporting (b) to use mine and my family’s photograph in reports sent to grantors and in social media or advertisements (c) Obtain my personal current and future credit report and inquiries from bureaus, as well as any and all information, verbal or written as deemed necessary that will assist improving my credit and/or assist me in obtaining a mortgage, rental or housing assistance. Including but not limited to Current and previous employment, Current and previous loans or extended credit, Current and previous residences , Banks, credit unions and all other accounts, Consumer credit reports. (d) Speak on my behalf, share and/or discuss my credit report and financial situation with any other entity such as but not limited to lenders, grantors, collection agencies, creditors, landlords or nonprofits which may offer me a mortgage or other housing and financial related assistance (e) Furthermore, in view of the fact that Mercy Housing & Human Development is a no-profit organization, I hereby release, hold harmless and waive all claims associated with these publications and marketing materials which I may have against Mercy Housing & Human Development and its employees.

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