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HOME
ABOUT
INTAKE
PROGRAMS
RESOURCES
- Free Home Inspections
DONATE
- Sponsors
CONTACT

HOME
ABOUT
INTAKE
PROGRAMS
RESOURCES
- Free Home Inspections
DONATE
- Sponsors
CONTACT

Intake Form

The first step in participating in any RiseUp Fund offering is to complete the Intake Form. This information will be kept confidential and once shared, you can sign up for any of our other programs.

Name *

First

Last

Email *

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

What is your gender?

Male
Female
Non-binary/Other
Prefer not to answer

What is your race?

Black or African American
Hispanic or Latino
American Indian or Alaska Native
Caucasian
Hawaiian or Other Pacific Islander
Prefer not to answer

What is your marital status?

Married
Single
Divorced
Domestic Partnership

Are you a single parent?

Yes
No

How many people live in your household?

Selected Value: 0

How many adults (18 years and older) live in your household (including you)?

Selected Value: 0

How many children (under 18 years) currently live in participant’s household?

Selected Value: 0

Which RiseUp Fund Program(s) are you interested in utilizing? *

Homebuyer Education Series
Home Purchase Financial Assistance
Homeowner Mentorship
IDA Program (Matched Savings Account)

What is your highest level of education completed? *

Some High School
High School Diploma/GED
Some College
Associate's Degree
Bachelor's Degree
Graduate Degree

What is your primary employment status? *

Employed full-time
Employed part-time
Employed more than full-time
In school or job training
Both Working and in school or job training
Laid off, waiting for call back
Retired

Have you successfully completed a Homebuyer Education Program within the past 2 years?

Yes
No

If yes, please upload your completion certificate

Click or drag files to this area to upload. You can upload up to 2 files.

Are you currently working with a Realtor to find your first home? *

Yes
No

How soon are you looking to buy a home? *

3 - 6 Months
6 - 12 Months
1 Year+

Have you ever owned a home before? *

Yes
No
Yes, but more than 3 years ago

Do you own a vehicle? *

Yes
No

Which Household Income Range do you fall in?

1 Person: $22,150 - $59,050
2 People: $25,300 - $67,450
3 People: $28,450 - $75,900
4 People: $31,600 - $84,300
5 People: $34,150 - $91,050
6 People: $37,190 - $79,800
7 People: $41,910 - $104,550
8 People: $46,630- $111,300
Prefer not to answer/don't know

Have you ever been a recipient of TANF or AFDC? *

Yes
No
Prefer not to answer

Do you currently receive SSI or SSDI? *

Yes
No
Prefer not to answer

Check the box for which bank accounts you use:

Checking Account
Savings Account
Retirement/Investment Account
Other

Do you currently or have you previously used direct deposit for your income? *

Yes
No

What is your current estimated savings? *

Under $1000
$1000 - $3000
$3000 - $5000
$5000 - $7500
More than $7500
Prefer not to answer/don't know

What is your current credit score? *

Under 590
590 - 630
630 - 670
670 - 710
Above 710
Prefer not to answer/don't know

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