HomeMHC Financial Evaluation Form

MHC Financial Evaluation Form

General Information
What Mental Health Counseling class are you currently enrolled in?*
Name*
First Middle Last
Email*
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State Zip
Cell Phone*
Education Level*
Gender*
Ethnicity/Race*
If other, please specify:
Preferred Method of Communication*
Is the Applicant a Veteran*
Household Status*
Other Information
What is your estimated credit score (if unknown type unknown)
Source used to pull your credit report (Ex. Credit Karma, TransUnion, etc.)
What is your total Savings?
Income Per Month
What is the applicants take home pay (Monthly)*
Employment Status*
Choose One
If other please specify
Employer
Other Income Sources
Source Amount

Click + to the left of Amount field to add more sources
Current Housing & Debt Status
Number of persons in Houshold*
Number of Dependents*
Housing Status*
Is Rent/Mortgage Delinquent?*
Month(s) Delinquent
Amount Delinquent
Do you have any judgements
Please select one
If yes how much Do you owe
Please choose one
List current balances for each debt individually*
Creditor Balance Monthly Payment Interest Rate

Click + to the left of Amount field to add more sources NOTE: The name of each creditor and estimated balances are needed for each debt you wish to include on this application. Not providing this information will delay our review and processing of your application.
Monthly Living Expenses
Fixed Expenses

(Please estimate monthly figures.)
Total Fixed Expenses
Rent/Mortgage
2nd Mortgage
Renter/Homeowner Insurance
Car Payment #1
Car Payment #2
Child Care
Child Support
Tax Installments
Savings
Flexible Expenses

(Please estimate monthly figures.)
Total Flexible Expenses
Groceries/Toiletries
Meals Out
School Lunches
Electricity Oil Gas
Water/Sewage/Garbage
Telephone/Cell Phone/Beeper
Family Clothing
Occupational Expenses
Dry Cleaning/Laundry
Gasoline
Bus Fares/Ride Shares/Parking
School - Tuition/Supplies
Barber/Beauty Shop
Books/Newspapers/Magazines
Movies/Sports/Entertainment
Gifts/Parties/Holidays
Cigarettes/Tobacco/Alcohol
Babysitter
Hobbies/Club Dues
Medical/Dental/Optical/Meds
Church/Charities
Pet Care
Home Maintenance
Lawn/Pool Maintenance/Security
Cable TV
Internet
Vacations/Travel
Periodic Expenses

(Please estimate monthly figures.)
Total Periodic Expenses
Property Taxes
Life Insurance
Health/Accident Insurance
Auto Insurance
Car Maintenance (Oil/Lube/Tires)
Total of ALL Expenses
Click here to view the Fraud Policy, Client Bill Of Rights, Privacy Policy, Fee Waiver Policy , Statement of Counseling/Education Services, Client Bill of Rights, Complaint Resolution Process, Non-discrimination Policy thought the below link
Electronic Signature (Required)*
First Last
By signing above you are agreeing that you have provide accurate information to Origin SC. You are also agreeing that you accept and you have been provided Fraud Policy, Client Bill Of Rights, Privacy Policy, Fee Waiver Policy , Statement of Counseling/Education Services, Client Bill of Rights, Complaint Resolution Process, Non-discrimination Policy
Name
This field is for validation purposes and should be left unchanged.

Source	Amount

Creditor	Balance	Monthly Payment	Interest Rate

MHC Financial Evaluation Form

General Information

Other Information

Income Per Month

Current Housing & Debt Status

Monthly Living Expenses

Fixed Expenses

Flexible Expenses

Periodic Expenses