Information will not be shared with any third party (e.g., credit agency or lender) without your explicit signed authorization.
"Client 1" refers to the primary applicant, "Client 2" (if applicable) refers to the spouse or co-signer.
Select the Type of Loan Counseling Service You Want
General Loan Counseling Service
Reverse Mortgage Counseling Service
Loan Crisis Counseling Service (for Defaulted Mortgages, Foreclosures, Crisis and Predatory Workout Counseling)
Home Improvement Counseling Service
General Information
Client 1 Client 2
Last Name
First Name
Middle Name
Suffix (Sr., Jr., etc.)
Social Security Number
Home Phone
Alternate Phone
Email Address
Birth Date
Number of Dependents
Gender Female
Female
Male
Marital Status Married Married
Additional Single Head of Household Single Head of Household
(check all that apply) Female Head of Household Female Head of Household
First Time Home Buyer First Time Home Buyer
US Veteran US Veteran
Owned Home in Last 3 Years Owned Home in Last 3 Years
Race American Indian/Alaskan Native American Indian/Alaskan Native
Asian/Pacific Islander Asian/Pacific Islander
Black/Non-Hispanic Black/Non-Hispanic
Hispanic Hispanic
White/Non-Hispanic White/Non-Hispanic
Other Other
Citizenship
Address
Client 1 Client 2
Street Address
City State
Zip
State
Zip
Residency Status Own
Own
County
Length of Occupancy Years
Months
Years
Months
Previous Address
Enter if the current address is less than two years.
Street Address
City State
Zip
State
Zip
Residency Status Own
Own
County
Length of Occupancy Years
Months
Years
Months
Employment
Employer Name
Street Address
City State
Zip
State
Zip
Contact Phone
Position/Title
Length of Employment Start Date
End Date
Start Date
End Date
Previous Employment
Enter if within the last two years.
Employer Name
Street Address
City State
Zip
State
Zip
Contact Phone
Position/Title
Length of Employment Start Date
End Date
Start Date
End Date
Part 3:
Income
Owner
If there are multiple clients, enter the name of the one responsible for the income.
Type of Income
Specify the type of income: salary, commissions, bonuses, etc.
Pay Cycle
Indicate how frequently the client receives this income: biweekly, hourly, monthly, semi-monthly, weekly, or yearly.
Owner Type of Income Amount Pay Cycle
Owner Type of Income Amount Pay Cycle
Owner Type of Income Amount Pay Cycle
Owner Type of Income Amount Pay Cycle
Owner Type of Income Amount Pay Cycle
Assets
Owner
If there are multiple clients, enter the name of the one who owns the asset.
Type of Income
Describe the nature of the asset: checking account, savings account, stock, pending tax refund, etc.
Institution
Enter the name of the bank or other financial institution holding the asset.
Owner Type of Asset
Institution Name Account Number Asset Value Available Funds
Owner Type of Asset
Institution Name Account Number Asset Value Available Funds
Owner Type of Asset
Institution Name Account Number Asset Value Available Funds
Owner Type of Asset
Institution Name Account Number Asset Value Available Funds
Owner Type of Asset
Institution Name Account Number Asset Value Available Funds
Liabilities
Owner
If there are multiple clients, enter the name of the one who has the liability.
Type of Liability
Describe the nature of the liability: credit line, mortgage, taxes, etc.
Owner Creditor Name Monthly Account Number
Type of Liability Balance Owed
Owner Creditor Name Monthly Account Number
Type of Liability Balance Owed
Owner Creditor Name Monthly Account Number
Type of Liability Balance Owed
Owner Creditor Name Monthly Account Number
Type of Liability Balance Owed
Owner Creditor Name Monthly Account Number
Type of Liability Balance Owed
Declarations (Credit Issues)
Owner
If there are multiple clients, enter the name of the one who had the issue.
Action Type
Specify one of the following: bankruptcy, foreclosure, judgement, lien, party to lawsuit, or repossession.
Owner Action Type Date Occurred Resolution Date
Owner Action Type Date Occurred Resolution Date
Owner Action Type Date Occurred Resolution Date
Non-Traditional Credit
Owner
If there are multiple clients, enter the name of the one responsible for this credit.
Credit Type
Specify one of the following: auto insurance, cable TV, child care, electric, gas, homeowner/renter's insurance, life insurance, local merchant account, medical bill, medical insurance, rent, school tuition, telephone, or water.
Owner Credit Type Avg. Monthly
Owner Credit Type Avg. Monthly
Owner Credit Type Avg. Monthly
Owner Credit Type Avg. Monthly
Owner Credit Type Avg. Monthly
How did you hear about New Jersey Citizen Action? Please include the person's name and phone number.
If you were referred by a bank, please list the name and phone number of the person you are working with.
Do you require a Spanish-speaking counselor?
How would you rate your overall credit?
Do you use oil to heat your home or apartment?
NEXT QUESTION, about repairs, is ONLY for Home Improvement Counseling Service applicants: What repairs need to be done?
Our Loan Crisis Counseling Service is for Defaulted Mortgages, Foreclosures, Crisis and Predatory Workout Counseling
1. What is the name of the company that sold you your home?
2. What is the name of the company that financed your home/gave you your mortgage?
3. Did you have an attorney at your closing? (If yes, did you hire the attorney on your own, or was the attorney recommended to you by the seller/lender)?
4. Were you charged high interest rates? (If yes, was this the rate you were promised by the lender?)
5. Were you charged a high loan fee, points, or other charges upfront?
6. Were you sold costly and unnecessary insurance policies upfront?
7. Were you charged a pre-payment penalty?
8. Are your monthly payments different than what you were told by the lender/seller?
9. After purchasing your home, did you find out that there were unpaid taxes or utility bills from previous owners?
10. Did the company that financed your home repeatedly refinance you? (If yes, did your payments increase after each refinance?)
11. Did a contractor/repairman recommend a lender to finance your repairs?
12. Were any promises made by the lender/seller that were not kept?
13. To your knowledge, was any information falsified or were any signature(s) forged on your closing documents?
Please choose the office that you would like to go to:
If you prefer, you may also print out this form, using your Web browser's Print command (be sure the cursor is within the form itself), complete it and send it to the Postal Mail address given directly above. Or you can Fax it to us at 973-643-8100. Thank you!
