Intake Form

Your Name(Required)

First Middle Last

Date of Birth(Required)

Spouse/Other

First Middle Last

Date of Birth(Required)

Physical Address(Required)

Street Address Address Line 2 City State ZIP Code

Mailing Address(Required)

Same as Physical Address

Enter a Different Mailing Address

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

Email(Required)

Where did you hear about us?(Required)

How would you like to report your household income?(Required)

Annual Household Income(Required)

Monthly Household Income(Required)

How much are you paid per hour?(Required)

How many hours per week do you work?(Required)

Your Weekly Income

The following information is requested by the Federal Government in order to monitor compliance with Federal laws prohibiting discrimination against individual(s) seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your request or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/national origin of the individual(s) completing the form on the basis of visual observation or surname.

Your Race(Required)

Ethnicity

Gender

Ethnicity

Are you the Head of Household?(Required)

How many adults are in your household?(Required)

Ages of Adults(Required)

Social Security Numbers of all Adults(Required)

How many children are in your household?(Required)

Ages of Children(Required)

Are you disabled?

Is your Spouse/Other disabled?

Are any of your dependents disabled?

Education Level You Have(Required)

Marital Status(Required)

Active Military?

Reason for completing intake form(Required)

907-780-3105

lending@hyfclending.com

5446 Jenkins Drive, Juneau, Alaska 99801