JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Post Purchase Intake
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email Address
Your answer
Name
*
Your answer
Phone Number
*
Your answer
Address
*
Your answer
Length of residency at current address
*
Your answer
Were you referred here? If yes, by who?
Your answer
Level of Education
Graduate School
College
Some college
High School
Primary School
None
Other:
Clear selection
Household Size
Your answer
Number of Adults
Your answer
Number of Children
Your answer
Familial Status
Single
Single Parent
Married
Co-Habitation
Other:
Clear selection
Head of Household?
Yes
No
Clear selection
Gross Income
Your answer
Source of Income
Your answer
Income as Percentage of Area Median Income
<50%
50%-79%
80%-100%
>100%
Clear selection
Current Mortgage
Your answer
Value of Home
Your answer
Debt
Your answer
Ethnicity
Hispanic
Not hispanic
Prefer not to answer
Clear selection
Race
Asian
Black or African America
Middle Eastern
Indigenous Persons or Pacific Islanders
White
Two or More Races
Prefer not to answer
Clear selection
Other information
Veteran
Senior
Limited English
Disabled
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Housing Help Inc..
Report Abuse
Forms
