HomeHECM Reverse Mortgage Counseling Intake Packet

HECM Reverse Mortgage Counseling Intake Packet

Please fill out this form if you are interested in Reverse Mortgage Counseling and a licensed counselor will reach out to you within 24 hours.

If you have any questions while filling out this form please call 843.628.4399 or email us.

HECM Counseling Intake Screening Application

Primary Applicant Name

First Last

Applicant Phone Number

Primary Applicant Email

Applicant Marital Status

Applicant Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Applicant Race

Hispanic/Latino

Applicant Highest Education

Veteran

Served Wartime

Is a Co-Applicant on this application?(Required)

Yes

Co-Applicant Information

Full Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship to Primary Applicant

Date of Birth

Phone Number (Co-Applicant)

Email (Co-Applicant )

Race

Hispanic/Latino

Highest Education

Veteran

Served Wartime

Who is listed as the Homeowner?

Is this your primary dwelling?

Year Built:

Year Purchased:

Type of Property:

If other, please specify:

Do you plan to remain in this home?

Estimated Property Value:

Total Owed on all loans that are attached to the property:

Do you have the following liens on the property?

If yes, how much?

Primary Mtg/Current HECM:

If yes, how much?

HELOC

If yes, how much?

Second Mortgage:

If yes, how much?

Other Lien(s):

Type:

Are your payments current?

If no, how far behind are you?

Have you received a notice of foreclosure?

Condition of Property

Repairs Needed:

Number of persons in household:

Household Income

Applicant Income

Co-Applicant Income

Other:

Total Income:

Other Assets (amounts)

Savings:

Retirement:

Investements:

Property Taxes (annual amount)

HO Insurance Cost (annual):

Have you been late on your property tax or homeowner's insurance in the past 3 years?

Credit Card Debt (total):

Other loans not attached to home (total)

Do you have IRS/State Debt?

Any other debts?

Have you been late on any debt payments in the last 3 years?

Are you in Arrears for debt not attached to your primary dwelling?

How much are you in arrears currently?:

Have you ever filed for Bankruptcy?

If yes, when?

I understand that my spouse must be present for this session:(Required)

I Accept

I Decline

Please list all whom will be attending this appointment:

Reason(s) for exploring a reverse mortgage:

Does the client have family or friends nearby to assist with errands or to look after them?

Lender Information:

Is the client working with a lender?

Counseling Access Code:

Company Name:

Loan Officer:

Lender Email:

Has the client received lender proposals?

Has the client signed anything?

By checking this box, I agree that I have been provided with Origin SC's Privacy Policy & Statement of Counseling Services (see below).(Required)

I agree to the privacy policy.

FRAUD POLICY

Family Services, Inc. DBA Origin SC (the Company) is committed to preventing, identifying, and reporting any fraudulent activity related to the Company’s services, activities and administration of grants. Fraud may include but is not limited to false statements provided by or to staff, contractors, clients, beneficiaries and stakeholders. Fraudulent activities may include but are not limited to knowingly misrepresenting income or expenses, assisting or counseling anyone to misrepresent facts or circumstances related to eligibility for programs or benefits, bribery, kickbacks, theft or embezzlement, forgery or alteration of documents, destruction or concealment of records, profiting from insider knowledge, or a conflict of interest. The Company will investigate any reports of fraud. The Company reserves the right to involve law enforcement authorities in its investigation. Any documented fraudulent activity may result in administrative or criminal action being taken against those involved including termination from any program sponsored by the Company or termination from employment by the Company. The Company will not retaliate against any party who reports fraud, criminal activities or other program irregularities. Any suspected fraudulent activity should be reported to the Company’s currently appointed Risk Manager with sufficient specificity to facilitate an investigation.
PRIVACY POLICY

Our agency is committed to assuring the privacy of individuals and/or families who have contacted us for assistance. We realize that the concerns you bring us are highly personal in nature. We assure you that all information shared both orally and in writing will be managed within legal and ethical considerations. The following are examples of how this data may be used:
ALL CLIENTS
1. To assist us in our work with you, our staff may seek supervision/consultation with professional colleagues within the agency and, where appropriate and necessary, with other resources in the community.
2. For the purpose of evaluating our services, gathering valuable research information and designing future programs, we may report case file information to various grantors and stakeholders.

COUNSELING ONLY
3. For counseling only clients, we will confirm with your creditors if asked:
a. Verification of appointment
b. Date of counseling
c. Disposition: i.e.,
1) Client will handle affairs on their own
2) Pending action

MORTGAGE DEFAULT/DEBT MANAGEMENT
4. For clients needing our intervention on your behalf through Mortgage Default or Debt Management, we will disclose the following information to your lender/creditors:
• Your address and home phone number, if published
• Total debt information
• Income, net and gross
• Living expenses
• A list of your creditors
• Personal information concerning your financial circumstances, but not lifestyle or personal habits
• Place of employment will be verified only
5. We collect nonpublic personal information about you from the following sources:
• Information we received from you on our applications or other forms you provide
• Information about your transactions with us, your creditors, or others, and
• Information we receive from a credit reporting agency
In all other situations, your information may be released to appropriate individuals or agencies ONLY UPON YOUR SIGNATURE BELOW PERMITTING US TO DO SO, OR when our staff has been served by a valid subpoena.
The following PRIVACY POLICIES detail circumstances under which we will release your information to a third party:
6. We may disclose some or all of the information that we collect, as described below, to creditors, or third parties who need this information in order for us to assist you after a counseling session. Information includes but is not limited to:
• Information we receive from your applications or other forms, such as your name, address, social security number, assets, and income
• Information about your transactions with us, your creditors, or others, such as your account balance, payment history, parties to transactions and credit card usage
• Information we receive from a credit reporting agency, such as your credit history
7. We may disclose all of the information that we collect, as described above, to creditors and related financial institutions who need this information in order to put you on a debt management plan (DMP) or mortgage workout.
8. We restrict access to nonpublic personal information about you to those employees who need to know that information to provide services to you. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your nonpublic personal information. However, several of our grantors require that we provide some nonpublic information about you in order to provide proof of counseling services provided and outcomes achieved.
9. Unless earlier revoked by client, this authorization will expire one year from the date signed. However, I/We give permission to ORIGIN, their grantors/stakeholders and their representative agents to follow-up with me as necessary for purposes of program compliance and/or evaluation.

By checking the box above, I/we agree that I/we have read and understand the Origin Privacy Policy and understand my nonpublic information may be released to appropriate individuals or agencies as necessary to assist me.
AFFILIATED BUSINESS ARRANGEMENT DISCLOSURE
Origin Realty, Inc. is a for-profit wholly owned subsidiary of Origin. Additionally, Origin, a non-profit 501(c)(3) organization, has several nonprofit divisions doing business as Financial Education & Coaching (FEC), Homeownership Promotion & Preservation (HPP), Family Violence Intervention (FVIP), Housing Stability, and Conservator Services. Origin Realty, Inc. provides real estate brokerage services for which it and its licensed real estate agents typically earn a commission. Origin SC provides various counseling, granting, lending and educational services for free or for cost of service fees.
Set forth below is the estimated charge or range of charges for the settlement services listed. Origin will NOT require you to use the services of Origin Realty or any affiliates as a condition for its services.
Origin Realty, Inc. will NOT require you to use the services of Origin SC as a condition of its brokerage services. THERE ARE FREQUENTLY OTHER SETTLEMENT SERVICE PROVIDERS AVAILABLE WITH SIMILAR SERVICES. YOU ARE FREE TO SHOP AROUND TO DETERMINE THAT YOU ARE RECEIVING THE BEST SERVICES AND THE BEST RATE FOR THESE SERVICES.
Provider/Partner Settlement Service Charge or Range of Charges
Origin SC- Homeownership Dept. Homebuyer Education and Counseling
One-on-One Counseling $0 to $199 paid for at time of initial counseling
Origin SC- Homeownership Dept. Credit and Financial Counseling Free or monthly $30
Origin SC - Housing Stability & Conservator Dept. - Free per court and government approved sliding scale
Origin SC - Family Violence Intervention Dept. Anger Mgmt., Domestic Violence Counseling $0 to $65 per session
Origin SC – Lending Dept. Mortgage Lending Legally allowed fees and/or interest. All loans must pass High Cost Mortgage Testing
Origin SC – Lending Dept.: Borrowers Supportive Services Mortgage Lending $99 paid at time of initial intake
Origin SC – Lending Dept./First Citizens (FC) Loan Servicing No charge to borrower for servicing. If payment is more than 15 days late, charge will be 4% of loan payment amount past due
Origin SC – Lending Dept./NeighborWorks America Ref: NeighborhoodLIFT Approved Lenders List $0 to $285 paid at closing, 0% interest forgivable loans
Origin Lending Dept./Community Loan Center of America (CLC) Small Dollar Lending Program $20 loan administrative fee plus 18% interest
Origin Realty Real Estate Brokerage Real Estate Sales Commission and or fees
Origin Realty Real Estate Brokerage Administration fee up to $350
Neighborhood Revitalization LLC Development Buyer’s purchase price
Mount Pleasance Housing for All (HFA) Application processing No charge to the borrower. HFA will be invoiced $110 for each session.

Fee Waiver Policy
The agency’s policy with regard to the availability of services for free or at a reduced rate based on a client’s ability to pay: Origin SC makes our services available to consumers who are experiencing financial difficulties. Counseling is provided to all persons regardless of religion, sex, race, national origin, or the ability to pay, etc. For all households that are at/or below 150% of the Federal Poverty Guidelines published by the US Department of Health & Human Services (DHHS) are eligible for a fee waiver or fee reduction. This determination will be made by the bankruptcy coordinator when household income and size are provided on our Counseling Application. During the follow up or counseling appointment, the coordinator will notify those who are eligible, and clients will have to provide income documentation to the bankruptcy coordinator, such as Social Security award letters, pay stubs, tax returns, etc.
I/We give permission to Origin Realty, Inc. to provide a copy of my/our HUD closing statement to Origin for statistical reporting purposes.
I/we have read this Disclosure, and understand that if Origin Realty, Inc. is referring me/us to Origin and/or if Origin is referring me/us to Origin Realty Inc. to purchase the above-described settlement service(s) and they may receive a financial or other benefit as the result of this referral.
I understand that a copy of the Origin, privacy policy will be made available to me for viewing upon request.
The Affiliated Business Arrangement Disclosure portion of this form is prepared and provided in compliance RESPA Section 8(c)(4). If you have questions or concerns you may direct them to: Caprice Atterbury, Origin 8084 Rivers Ave, Suite 100, N. Charleston, SC, 29406 Phone: 843 628 5004.
By checking this box, I/we agree that I/we have read, understand and agree to all contract provisions, authorizations and disclosures listed above (page 1 and page 2). It has been explained to me/us by my Home Purchase/Credit Advisor that I/we may choose any
lender or real estate agent of my/our choice to complete my/our home purchase transaction.

I/We give permission for my /our closing attorney, loan officer, or real estate agent to provide copy of my/our signed Closing Disclosure to Origin Realty Inc. upon the closing of my mortgage.

This field is for validation purposes and should be left unchanged.