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.

LIMITED ASSISTANCE MAY BE AVAILABLE

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?

Monthly housing payment:

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)

Business Practice Disclosure

Our agency provides the following HUD one-on-one housing counseling services:
Pre-purchase/homebuying; post-purchase; financial management for homeowners; rental topics and foreclosure prevention.
Our agency also provides the following services and group education workshops:
Pre-purchase/homebuyer education

Relationships with Industry Partners:

Our agency has financial or exclusive relationships, or both, with specific industry partners, including, Mississippi Home Corporation, Cadence Bank, The First Bank, Trustmark Bank, Community Bank, First Federal Bank, Hope FCU, Hancock-Whitney Bank, and Songe Insurance. Also include other program federal entities that the agency may have a relationship (other than a partnership) such as HUD, Federal Home Loan Bank, or U.S. Department of Agriculture Rural Housing Service

No Client Obligation:

There is no obligation to receive, purchase, or use any product or service offered by MHHD or any services of its industry partners or other party in exchange for your receiving HUD housing counseling services.

Alternatives:

As a condition of our services, and in alignment with meeting our counseling goals, and in compliance with HUD’s Housing Counseling Program requirements, we may provide information on alternative services, programs, and products available to you, if applicable and known by our staff.
I have read and received a copy of this disclosure.

Please provide your initials to authorize:

MHHD Client Agreement Part One

I understand that:

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.
A counselor may answer questions and provide information about bankruptcy, but not give legal advice.
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 loan products or housing programs.
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 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:

All actions, claims, demands, and causes of action, for 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.
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 counseling, advice, work performed or otherwise.
All claims or allegations of personal injury, property loss, or damage occurring on the premises.
any claims and causes of action arising from errors or omissions related to my participation in MHHD counseling.

I agree to:

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

Please provide your initials to authorize:

MHHD Client Agreement Part Two

I authorize Mercy Housing & Human Development, Inc to:

use my name in any current and future publications or reporting.
to use mine and my family’s photograph in reports sent to grantors and in social media or advertisements.
Obtain my personal current and future credit report and inquiries from bureaus, as well as 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

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.
Furthermore, since 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.

By signing below, I confirm that I have read, understand, agree, and will adhere to the above policy and procedures.

Please provide your initials to authorize:

NOTE: If you have an impairment, disability, language barrier, or otherwise require an alternative means of completing this form or accessing information about housing counseling, please talk to your housing counselor about arranging alternative accommodations.

Mercy Housing and Human Development (MHHD) 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 considerations. Additionally, we want you to understand how we use the personal information we collect about you. 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 MHHD collect about you?

We collect personal information about you from the following sources:

Information that you provide on applications, forms, email, or verbally.
Information about your transactions with us, our affiliates, or others
Information we receive from your creditors or employment references.
Credit Reports

What categories of information do we disclose and to whom?

We may disclose the following personal information to financial service providers (such as HUD, Mississippi Home Corporation, Cadence Bank, The First Bank, Trustmark Bank, Community Bank, First Federal Bank, Hope FCU, and Hancock-Whitney Bank) Federal, State, and nonprofit partners for program review, monitoring, auditing, research, and/or oversight purposes, and/or any other pre-authorized 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 your credit 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 would personally identify you in any way. This is done 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.

How is your personal information secured?

We restrict access to your nonpublic personal information to MHHD employees who need to know that information 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 MHHD to not disclose your nonpublic personal information to third parties (other than disclosures made to project partners and those permitted by law). However, if you choose to opt out, we will not be able to answer any questions from your creditors, which may limit MHHD ability to provide services such as foreclosure prevention counseling. If you choose to opt-out, please sign below under the “Opt-Out” clause. If you choose to release your information as stipulated in this Privacy Policy, sign under the “Release” clause. You may change your decision any time by contacting our agency.

Please select whether you would like to release your information OR opt out:

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.