1-on-1 Housing Services Counseling Registration Form Disclosure Statement - Acknowledgement Disclosure Statement – AcknowledgementAfter reading, please sign the acknowledgment at the bottom of this page. Valley Community Development’s Sustainable Homeownership Center provides a variety of services, including homeownership services to first-time buyers and homeowners. We provide buyer readiness counseling including financial literacy, budgeting, foreclosure prevention, first-time buyer workshops, post-purchase workshops, and grants for down payment assistance when available. We market affordable housing units available for sale to income-eligible first-time buyers. Valley follows strict rules to protect your confidentiality. The personal data collected including name, street address, email address, and any other personally identifying information is protected by the Privacy Act of 1974. You will never be named in any reports. Your anonymous response may be looked by funders or contractors hired by funders to collect and analyze data, your name or street address will not be reported. Income, city, state, zip code, family size, and other demographic data will be reported. Contractors of HUD or any City/State agency are covered by the same Privacy Act requirements to protect your privacy and staff must demonstrate that they have systems in place to protect against data disclosure.· Funding Sources Include:• Mass Housing Partnership Fund Board (MHP)• Massachusetts Rehabilitation Commission (MRC)• City of Northampton• City of Easthampton• Town of Amherst• MA Division of Banks • Florence Bank• bankESB• PeoplesBank • Greenfield Cooperative Bank• Greenfield Savings Bank • Amherst Community Land TrustValley Community Developments’ workshop participants are under no obligation to utilize any of Valley’s services or programs or to purchase or rent property owned by Valley to receive counseling services. You are under no obligation to use the services of any funding source or by any of our business Supporters. Counseling services are free of charge and there are no income restrictions for homeownership or foreclosure prevention counseling to clients, however, it is our goal to serve households at or below 80% of area median income, people of color, and minority households who may be underserved in our community. Valley’s Staff provides a verbal disclosure at the beginning of each class, counseling session and provides a copy via email or in person and encourages participants to shop around.Ok By entering your name and checking the box above, you acknowledge that you have read the above disclosure If a second household member will be participating in 1-on-1 Counseling with you, they must also read the above and type their name here in acknowledgement. If you are participating alone, please type N/A. Contact Information & Demographics Legal First Name Legal Last Name Preferred Name PronounsHe/himShe/herThey/themJust my nameOther What pronouns do you use? Email Cell Phone Home / Alternate Phone We take your privacy seriously and maintain strict confidentiality. Providing the following information is optional but it is needed for reporting and statistical purposes. GenderMaleFemaleNonbinaryOtherChoose not to respond Are you 60 or more years of age?YesNoChoose not to respond Are you disabled?YesNoChoose not to respond Do you identify as LGBTQ?YesNoChoose not to respond Are you a Veteran?YesNoChoose not to respond Valley asks the following two questions as a requirement from several funding sources that help make our programs free to the community. Do you consider yourself Hispanic or Latino?YesNoChose not to respond Select the following race you identify with: AsianBlack or African AmericanNative American or Alaskan NativeNative Hawaiian or Pacific IslanderWhiteMultiracialChose not to respondRacial categories defined by OMB & US Census. For us to address the needs of our community, it's important to us that we learn about the diversity of those we serve. Please select all that apply:ArabAfricanAfrican AmericanAsianBlackCaribbeanEast AsianLatino/Latina/LatineMiddle Eastern or North AfricanNative AmericanNative AlaskanNative HawaiianPacific IslanderSouth AsianWhiteOtherChose not to respond Other: Are you an immigrant?YesNoChoose not to respond What is your native language? Do you consider yourself a minority?YesNo Do you have a spouse or partner who would like to register?Please select... Yes No Spouse or Partner Information & Demographics Legal First Name Legal Last Name Preferred Name PronounsHe/himShe/herThey/themJust my nameOther What pronouns do you use? Email Cell Phone Home / Alternate Phone We take your privacy seriously and maintain strict confidentiality. Providing the following information is optional but it is needed for reporting and statistical purposes. GenderMaleFemaleNonbinaryOtherChoose not to respond Are you 60 or more years of age?YesNoChoose not to respond Are you disabled?YesNoChoose not to respond Do you identify as LGBTQ?YesNoChoose not to respond Are you a Veteran?YesNoChoose not to respond Valley asks the following two questions as a requirement from several funding sources that help make our programs free to the community. Do you consider yourself Hispanic or Latino?YesNoChose not to respond Select the following race you identify with: AsianBlack or African AmericanNative American or Alaskan NativeNative Hawaiian or Pacific IslanderWhiteMultiracialChose not to respondRacial categories defined by OMB & US Census. For us to address the needs of our community, it's important to us that we learn about the diversity of those we serve. Please select all that apply:ArabAfricanAfrican AmericanAsianBlackCaribbeanEast AsianLatino/Latina/LatineMiddle Eastern or North AfricanNative AmericanNative AlaskanNative HawaiianPacific IslanderSouth AsianWhiteOtherChose not to respond Other: Are you an immigrant?YesNoChoose not to respond What is your native language? Do you consider yourself a minority?YesNo Do you have a spouse or partner who would like to register?Please select... Yes No If you live in a single parent household, please state the gender of the head of household:Male FemaleNot Applicable Address City State Zip Code How many people live in your household? Combined gross annual income Please enter a number only, with no characters. Do you rent your home, or do you own your home? I rent my homeI own my homeMy housing situation is not described above. What is the amount of your housing payment? Please include any taxes or condo fees. What is the amount of your rental payment? What is your housing situation? If you are trying to buy a home and have been approved for a mortgage, what type do you have?MHP ONE MortgageConventionalFHAUSDAOtherNot sureI have not been approved yet Would you like to subscribe to our newsletters?YesNo How did you hear about us? WebsiteSocial mediaAnother organizationFamily/friendsFlyerNewsletterOther Other Contact Information Contact Us