Housing Counseling
Foreclosure Prevention
12751 New Brittany Blvd, Suite 100, Fort Myers, FL 33907 | (239) 652-4663 | Habitat4Humanity.org
What is Foreclosure Prevention? Foreclosure prevention counseling can help
homeowners understand their state's foreclosure process, identify options for
avoiding foreclosure, and provide advice and resources to help them decide on
alternatives.
How do you get started? If you need Foreclosure Prevention housing counseling,
complete the Foreclosure Prevention Packet with forms and required
documentation listed on the
following pages. Once we receive your Packet, we
can schedule an appointment with one of our HUD-certified housing advisors for your
one-on-one counseling session.
Where to submit your Foreclosure Intervention Packet? You can drop off your
Foreclosure Prevention Packet at our administrative office at 12751
New Brittany
Blvd, Suite 100, Fort Myers, FL 33907, during regular business hours (Monday –
Friday from 8:00 am - 4:30 pm). Our Intake Coordinator will review it to ensure your
packet is complete. You can also mail it to our administrative office.
Did you know that Habitat for Humanity of Lee and Hendry Counties, Inc. is a non-profit
HUD approved housing counseling agency? Meaning we provide educational workshops and
a full spectrum of housing counseling services.
What is Housing Counseling? Our Housing Counseling program provides counseling
to consumers on seeking, financing, maintaining, renting, or owning a home. Our HUD-
certified Housing Advisors are experienced, trained professionals, who can provide you with
one-on-one housing counseling and guidance to help you make the right choices. The guidance
you receive is based on your need, plus, your current and future financial capability.
Homeowners facing foreclosure need to know what options are available to them. The path to
foreclosure is determined by state law. However, homeowners are also protected under federal
consumer protection laws and may have options for avoiding foreclosure depending upon the
mortgage lender.
If you have questions related to the Packet and how to get started with housing counseling, please
contact our Housing Counseling Team by calling at 239-652-1675 or by e-mail:
HousingCounseling@habitat4humanity.org
Housing Counseling
Foreclosure Intervention Packet
This is NOT an application for the Habitat Homeownership Program
1. Foreclosure Prevention Counseling Form - Fill it out as accurately as possible. This is required for opening your housing
counseling file.
2. Authorization for the Release of Information - F
ill it out and sign it. This will authorize us to contact your lender/servicer
on your behalf.
3. Monthly Household Spending Plan - F
ill it out as accurately as possible. It will be reviewed during the one-on-one
counseling session.
4. Mortgage Information Form – F
ill it out as accurately as possible. This will help the housing advisor review your mortgage
information and options.
5. Housing Counseling Disclosure Form - P
lease be sure to read it carefully. Then, sign to acknowledge that you have read
and understand the form.
6. Privacy Statement and Notice - P
lease be sure to read it carefully. Then, sign to acknowledge you have read and
understand the form
Use the following checklist to help you collect everything you need before submitting your Foreclosure
Prevention Packet (please make copies of all required documents, if applicable).
***Include any other legal documents that pertain to your mortgage. If you have more than one mortgage loan,
please bring documentation for all of them.
Note: If you cannot find some of these documents please still come to the appointment. Do your best to gather these
documents, it will make your time with an advisor more effective with the proper documentation.
Please make sure to submit the following forms included in your Foreclosure 3UHYHQWLRQ Packet:
Copies of Photo IDs (Driver’s License)
Please provide a legible copy of your photo ID in color
Proof of Income
If employed:
Copies of last four paystubs
If self-employed:
Copies of most recent tax returns (including 1099 forms and Schedule C)
Current year-to-dat
e Profit & Loss Statement
Proof of any other source of income (if applicable)
Bank Statements
Copies of the last 2 months of bank statements for all bank accounts
Latest bills
Homeowners’ association, gas, electric, water, garbage, phone, cell phone, internet, cable TV, car
loan(s), credit cards, student loans, other loans or bills.
The most recent statement from your lender(s).
Most recent mortgage statement
Missing payments (if applicable)
Most recent letter from the attorney for your lender (if applicable)
Truth in Lending Disclosure, HUD1 Settlement Statement, Mortgage Note and Riders to the Note
.
12751 New Brittany Blvd, Suite 100, Fort Myers, FL 33907 | (239) 652-4663 | Habitat4Humanity.org
Housing Counseling
Foreclosure Prevention
Date Received: CM#: Housing Advisor:
Name:
Name:
Social Security Number Social Security Number
Phone: Phone:
Email: Email:
Address Address
City State Zip Code City State Zip Code
Time at current address: Time at current address:
Race (please select): Race (please select):
Ethnicity (please select “yes” or “no”). Ethnicity (please select “yes” or “no”).
Hispanic: Hispanic:
Are you a U.S. citizen or a Permanent Resident? Are you a U.S. citizen or a Permanent Resident?
Marital Status (please select): Marital Status (please select):
Gender (please select): Gender (please select):
Disabled (please select) ?
Disable
d
(please select) ?
THIS IS NOT AN APPLICATION FOR THE HABITAT HOMEOWNERSHIP PROGRAM
FORM #1FOR INTERNAL USE
You should select both a “Race” category and a “yes” or “no” for Hispanic
origin)
You should select both a “Race” category and a “yes” or “no” for Hispanic
origin)
HOUSING COUNSELING FORECLOSURE PREVENTION
Birth Date (MM/DD/YYYY) Birth Date (MM/DD/YYYY)
CLIENT 1 CLIENT 2
Please print clearly and complete the required information as accurate as possible
White
AsianNative Hawaiian/Other Pacific Islander Asian and White
American Indian/Alaskan Native
Black or African American
White
Asian
Native Hawaiian/Other Pacific Islander
Black or African American
Yes No Yes No
Yes
No
Yes No
Single
Married Divorced Separated Widowed
Single
Married Divorced Separated Widowed
Male Female
Male Female
Yes
No
Yes
No
American Indian/Alaskan Native
American Indian or Alaska Native and White
Black or African American and White
Other Multiple Race
American Indian or Alaska Native and Black or African American
Asian and White
American Indian or Alaska Native and White
Other Multiple Race
Black or African American and White
American Indian or Alaska Native and Black or African American
Page 1 Foreclosure Intake form.xlsx
_________________________________________________________________________________
Current Employer: Current Employer:
Title
Hire Date (mm/dd/yy)
Title
Hire Date (mm/dd/yy)
Phone: Phone:
Address Address
City State Zip Code City State Zip Code
Please select: Please select:
# Hours per week: # Hours per week:
# Hours per week: # Hours per week:
Pay Rate:
$
Pay Rate:
$
Is this amount paid Is this amount paid
Other Employer: Other Employer:
Title
Hire Date (mm/dd/yy)
Title
Hire Date (mm/dd/yy)
Phone: Phone:
Address Address
City State Zip Code City State Zip Code
Please select: Please select:
# Hours per week: # Hours per week:
# Hours per week: # Hours per week:
Pay Rate:
$
Pay Rate:
$
Is this amount paid Is this amount paid
Rural Area Status (please select): Limited English Proficiency Status (please select):
Annual Family or Household Income :
$
Primary Employment
Other Employment (if applicable)
Self-employment Income
Social Security
Retirement Pension
Alimony/Child Support
Public Assistance
Other Income
If you have a second job, please specify:
EMPLOYMENT - CLIENT 1 EMPLOYMENT - CLIENT 2
EMPLOYMENT HISTORY
HOUSEHOLD INFORMATION
INCOME
Type of Income
Please Print Clearly
CLIENT 2
Monthly Amount $
CLIENT 1
Monthly Amount $
Part-time
Full-time
Part-time
Full-time
Hourly Weekly
Every 2 weeks
Bi-monthly Monthly
Hourly Weekly
Every 2 weeks
Bi-monthly Monthly
Part-time
Full-time
Part-time
Full-time
Hourly Weekly
Every 2 weeks
Bi-monthly Monthly
Hourly Weekly
Every 2 weeks
Bi-monthly Monthly
Household lives in a rural area
Household does not live in a rural area
Household is Limited English Proficient
Household is not Limited English Proficient
Page 2 Foreclosure Intake form.xlsx
Please Print Clearly
Please list an
y
debts
y
ou have
,
includin
g
credit cards
,
auto loans
,
student loans
,
p
ersonal loans and child su
pp
ort.
Do NOT include rent or utilities.
Paid To
1. Auto Loan
2. Credit Card 1
3. Credit Card 2
4. Credit Card 3
5. Credit Card 4
6. Student Loan
7. Personal Loan
8. Furniture Store
9. Child Support
10. Other
Please use additional sheets if necessary.
Please answer the following questions:
CLIENT 1 CLIENT 2
Do you make payments on time?
Are you currently in Chapter 13 bankruptcy?
Have you had a Chapter 7 bankruptcy?
If yes, when was it discharged?
Has your lender filed a foreclosure lawsuit against you?
ASSETS / SAVINGS / INVESTMENTS
Please list the approximate value of the following:
Current balance in $
Are you about to receive additional funds (e.g., tax refunds, property sales, etc.)? (select)
If yes, how much? $
Other Liquid Funds
Retirement accountS (e.g. 401k or IRA)
Securities (stocks, bonds, etc.)
CDs
Cash
Savings account
Checking account
CLIENT 2CLIENT 1
LIABILITIES/DEBT
CLIENT 2CLIENT 1
Please Print Clearly
Monthly
Payment $
Current BalanceCurrent Balance
Monthly
Payment
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes
No
Yes No
Page 3 Foreclosure Intake form.xlsx
LIVING EXPENSES (Monthly)
Please complete Spending Plan (Form #3)
REQUIRED DOCUMENTATION (Please include)
You are required to submit the documentation listed in the "Checklist for your One-on-One Counseling Session"
ADDITIONAL INFORMATION
CLIENT 1 CLIENT 2
Do you want to keep the house?
Are you working with a lawyer?
Have you applied for any funding or help?
Most convenient time for an individual appointment?
I authorize the Housing Advisors to:
(a) pull my/our credit report to review my/our credit file for housing counseling in connection with my pursuit on a
to receive Foreclosure Prevention
(b) pull my/our credit report and review my/our credit file for informational inquiry purposes; and
(c) to share my/our personal and financial information with my lender in connection with preventing
foreclosure (if possible).
I/We understand that the Housing Advisor provide confidential foreclosure prevention counseling after
which I will receive a written action plan consisting of recommendations for handling my credit and finances, possibly
including referrals to other agencies as appropriate;
I/We understand that a housing advisor may answer questions and provide information but not give legal advice.
If I want legal advice, I will be referred for appropriate assistance
I/We understand that any intentional or negligent representation(s) of the information contained on this form may
result in civil liability and/or criminal liability under the provisions of Title 18, United States Code, Section 1001.
Client 1 - Signature Date
Client 2 - Signature Date
AUTHORIZATION
Yes No
Yes
No
Yes No
Yes No
Yes No
Yes No
AM
AMPM
PM
Page 4 Foreclosure Intake form.xlsx
AUTHORIZATION FOR THE RELEASE OF INFORMATION
Date: __________________________
TO: ____________________________ ________________________________
(mortgage servicer name)
______________________________________________________________ (
mortgage servicer address)
ddEd/KE͗>ŽƐƐDŝƟŐĂƟŽŶĞƉĂƌƚŵĞŶƚ
RE: Account Number: _______________________________________________
Borrower(s): _______________________________________________________
WƌŽƉĞƌƚLJĚĚƌĞƐƐ͗ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
Dear Madam/Sir:
I/We are working with HABITAT FOR HUMANITY OF LEE AND HENDRY COUNTIES- a non-ƉƌŽĮƚHUD-
ĂƉƉƌŽǀĞĚŚŽƵƐŝŶŐĐŽƵŶƐĞůŝŶŐĂŐĞŶĐLJ, ŽŶĂƉůĂŶƚŽƌĞƐŽůǀĞŵLJͬŽƵƌŵŽƌƚŐĂŐĞĚĞůŝŶƋƵĞŶĐLJ͘/ͬtĞŚĞƌĞďLJ
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ůŝĞŶƚ^ŝŐŶĂƚƵƌĞ Date
Co-ůŝĞŶƚ^ŝŐŶĂƚƵƌĞ Date
WƌŽƉĞƌƚLJAddress: ______________________________________________________________________
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&ŽƌŵηϮ
&Žƌŵηϯ
Date:
Phone #:
Income
Net Income:
Fixed Expenses
Charity
Dining
Food and Groceries
Gifts
Public Transportation
Pet Expenses
Child Care
Clothing
Fitness Membership
Laundry / Cleaning
Entertainment
Miscellaneous
Client 1- Signature
Housing Advisor
Total Expenses:
Stick to your budget and track your expenses
each month
Discretionary Expenses
Client 1- Signature
Housing Counseling
Foreclosure Intervention Packet
Mortgage Information Form
Homeowner Name(s): ______________________________________________________________
Date: __________________________
Mortgage Info: First Mortgage / CD Second Mortgage / CD
Servicing Company Name:
Account Number:
Contact Person’s Name:
Contact Person’s Phone Number:
Contact Person’s Fax Number:
Originating Lender:
Origination Date:
Origination Amount:
Monthly payment amount:
$
$
Property taxes escrowed?
Yes__ No___ $_______
Yes__ No___ $_______
Homeowners ins. escrowed?
Yes__ No___ $_______
Yes__ No___ $_______
Forced place insurance? Yes__ No___ Yes__ No___
Loan type (circle one)
CD / Deferred Lien / FHA Ins. Conv. / Mobile
Home Other / Unins Conv / RD / VA
CD / Deferred Lien / FHA Ins. Conv. / Mobile
Home Other / Unins Conv / RD / VA
Loan Purpose (circle one):
Purchase / Purchase Assistance Refinance /
Second / HELOC
Purchase / Purchase Assistance Refinance /
Second / HELOC
Term (in years):
Interest rate:
%
%
Interest rate (circle one)
Fixed / ARM Option ARM /
Interest Only Fixed / ARM Option ARM / Interest
First reset date:
Reset Interval (in months):
Periodic cap:
Lifetime cap:
Balloon amount:
$
$
Balloon date:
Prepayment amount:
Prepayment, years in effect:
When did the mortgage company last accept a payment?
/ / / (mm / dd / yy) How
much was the payment? $_________________
/ / / (mm / dd / yy) How
much was the payment? $_________________
Previous defaults? Yes__ No___ Yes__ No___
Has the homeowner talked to the servicer?
Yes__ No___
Yes__ No___
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Page 1 of 3 Housing Counseling Program Disclosure
Ver 2 – Updated 11/15/22
Habitat for Humanity of Lee and Hendry Counties, Inc.
Housing Counseling Program
12751 New Brittany Blvd, Fort Myers, FL 33907
Ph: (239) 652-4663 / Fax: (239) 652-0386
HOUSING COUNSELING PROGRAM DISCLOSURE FORM
NOTE: If you have an impairment, disability, language barrier, or otherwise require an alternative means of completing this
form or accessing information about our housing counseling program, please inform our housing counselor program staff so
alternative accommodations may be arranged.
Agency Description and Program Purpose: Habitat for Humanity of Lee and Hendry Counties, Inc. is
a nonprofit, HUD-approved comprehensive housing counseling agency. We provide education workshops
and a full spectrum of housing counseling including pre-purchase, foreclosure prevention and non-
delinquency post-purchase counseling. We serve all clients regardless of income, race, color,
religion/creed, sex, national origin, age, family status, disability, or sexual orientation/gender identity. We
administer our programs in conformity with local, state, and federal anti-discrimination laws, including the
federal Fair Housing Act (42 USC 3600, et seq.).
Services Offered
Pre-purchase Counseling – One-on-one homebuyer counseling to clients seeking to achieve
homeownership. Assistance is offered in developing an action plan to help homebuyers reach their home
buying goal.
Financial Management/Budget Counseling – One-on-one counseling designed to help individuals create
and manage a budget, manage household debt, and learn ways to reach financial goals.
Home Improvement and Rehabilitation Counseling – One-on-one counseling designed to assist in
developing an action plan to help homeowners reach their home improvement or home rehabilitation goals.
Mortgage Delinquency and Default Resolution Counseling – One-on-one counseling designed to help
homeowners get current on their mortgage payments, work out a payment agreement with their lender, or
navigate the sale or foreclosure process.
Pre-Purchase Homebuyer Education Workshops – HUD approved 8-hour group workshop on topics
that will prepare the homebuyer to make informed home purchase decisions. Topics include homebuyer
readiness, managing money, understanding credit, obtaining a mortgage loan, shopping for a home, and
protecting your investment.
Financial, Budgeting and Credit Workshops – Group workshops to prepare individuals to make wise
financial decisions. Topics include preparing and managing a budget, managing, and reducing debt, tips
and tools for managing and saving money and preparing for future expenses.
Non-Delinquency Post-Purchase Homeowner Workshops – Group workshops on topics to prepare
homeowners for the opportunities and challenges brought about by buying a new home. Topics include
benefits of homeownership, money matters, maintaining your home and community involvement.
&Žƌŵηϱ
Page 2 of 3 Housing Counseling Program Disclosure
Ver 2 – Updated 11/15/22
Additionally, Habitat for Humanity of Lee and Hendry Counties, Inc. has a homebuyer program,
an owner-occupied repair program and a rental program for residents of Lee and Hendry
Counties
. You are not obligated to participate in this or other Habitat for Humanity programs and
services while you are receiving housing counseling from our agency.
As a housing counseling program participant, please affirm your roles and responsibilities along
with the following disclosures and initial, sign, and date the form on the following page.
Agency Conduct: No Habitat for Humanity of Lee and Hendry Counties, Inc. employee, officer, director,
contractor, volunteer, or agent shall undertake any action that might result in, or create the appearance of,
administering counseling operations for personal or private gain, provide preferential treatment for any
person or organization, or engage in conduct that will compromise our agency’s compliance with federal
regulations and our commitment to serving the best interests of our clients.
Agency Relationships: Habitat for Humanity of Lee and Hendry Counties, Inc’s Counseling Program has
professional affiliations with HUD, The State of Florida, Lee County, Hendry County, The City of Fort Myers,
The City of Cape Coral, The City of Bonita Springs, the City of Labelle, Florida Housing Coalition, and banks
including SunTrust Bank, Iberia Bank, Florida Community Bank, BB&T, FineMark, EverBank, Regions, Bank
of America, and Northern Trust. As a housing counseling program participant, you are not obligated to use
the products and services of Habitat for Humanity of Lee and Hendry Counties, Inc., or our industry partners.
Alternative Services, Programs, and Products & Client Freedom of Choice: Habitat for Humanity of
Lee and Hendry Counties, Inc. has a homebuyer program. However, you are not obligated to participate in
this or other Habitat for Humanity programs and services while you are receiving housing counseling from
Client and Counselor Roles and Responsibilities in One-on-One Counseling
Counselor’s Roles and Responsibilities
Client’s Roles and Responsibilities
➢
Reviewing your housing goal and your
finances;
which include your income, debts,
assets, and
credit history.
➢
Preparing a Client Action Plan that lists the steps
that you and your counselor will take to
achieve
your housing goal.
➢
Preparing a household budget that will help you
manage your debt, expenses, and savings.
➢
Your counselor is not responsible for achieving
your housing goal but will provide guidance
and
education in support of your goal.
➢
Neither your counselor nor Habitat for Humanity’s
employees, agents, or directors may provide
legal
advice.
➢
Completing the steps assigned to you in
your
Client Action Plan.
➢
Providing accurate information about your
income, debts, expenses, credit,
and
employment.
➢
Attending meetings, returning calls, providing
requested paperwork in a timely manner.
➢
Notifying Habitat for Humanity or your
counselor
when changing housing goal.
➢
Attending educational workshop(s) as
recommended.
➢
Retaining an attorney if seeking legal advice
and/or representation in matters
such as
foreclosure or bankruptcy
protection.
Termination of Service: Failure to work cooperatively with your housing counselor and/or Habitat for
Humanity
will result in the discontinuation of counseling services. This includes, but is not limited
to,
missing
three consecutive appointments, failure to provide necessary documents for workout
resolution,
withholding
pertinent information pertaining to your case and failure to inform
Habitat for Humanity of
a
ssistance received from another agency within the last year.
Page 3 of 3 Housing Counseling Program Disclosure
Ver 2 – Updated 11/15/22
our agency. You may consider seeking alternative products and services from entities including the Federal
Housing Administration (FHA), Lee County Housing Development Corporation, and USDA for first-time
homebuyer loan programs. You are entitled to choose whatever real estate professionals, lenders, and
lending products that best meet your needs.
Referrals and Community Resources: You will be provided a community resource list which outlines the
county and regional services available to meet a variety of needs, including utilities assistance, emergency
shelter, transitional housing, food banks, and legal aid assistance. This list also identifies alternative agencies
that provide services, programs, or products identical to those offered by Habitat for Humanity and its
exclusive partners and affiliates.
Privacy Policy and Relevant Information: I/we acknowledge that I/we received a copy of the following:
_____ Habitat for Humanity of Lee and Hendry Counties, Inc’s Privacy Policy
_____ “Know the Signs of Housing Discrimination” sheet
Errors and Omissions and Disclaimer of Liability: I/we agree Habitat for Humanity of Lee and
Hendry Counties, Inc., its employees, agents, and directors are not liable for any claims and causes of
action arising from errors or omissions by such parties or related to my participation in Habitat for
Humanity of Lee and Hendry Counties, Inc’s. counseling program, and I hereby release and waive all
claims of action against Habitat for Humanity of Lee and Hendry Counties, Inc., and its affiliates. I
have read this document, understand that I have given up substantial rights by signing it, and have
signed it freely and without any inducement or assurance of any nature and intend it to be a complete
and unconditional release of all liability to the greatest extent allowed by law. If any provision of this
document is unenforceable, it shall be modified to the extent necessary to make the provision valid and
binding, and the remainder of this document shall remain enforceable to the full extent allowed by law.
Quality Assurance: In order to assess client satisfaction and in compliance with grant funding
requirements, Habitat for Humanity of Lee and Hendry County, Inc., or one of its partners, may contact
you during or after the completion of your housing counseling service. You may be requested to complete
a survey asking you to evaluate your client experience. Your survey data may be confidentially shared
with Habitat for Humanity of Lee and Hendry Counties, Inc. grantors such as HUD or one of our
professional affiliates.
I/we acknowledge that I/we received, reviewed, and agree to Habitat for Humanity of Lee and
Hendry Counties, Inc’s Housing Counseling Program Disclosures.
Signature Client Printed Name Date
Signature Client Printed Name Date
Habitat for Humanity of Lee and Hendry Counties, Inc.
Privacy Statement and Notice
At Habitat for Humanity of Lee and Hendry Counties, Inc., we are committed to keeping your information private. We
recognize the importance clients, applicants, partner families, tenants, and homeowners place on the privacy and
confidentiality of their information. While new technologies allow us to more efficiently serve our customers, we are
committed to maintaining privacy standards that are synonymous with our established and trusted name.
When collecting, storing, and retrieving client, applicant, partner family, tenant, and homeowner data –such as tax
returns, pay stubs, credit reports, employment verifications and payment history– internal controls are maintained
throughout the process to ensure security and confidentiality.
We collect nonpublic personal information about you from the following sources:
x Information we receive from you on intake forms, applications or other forms;
x Information about your transactions with us, our affiliates, or others;
x Information we receive from a consumer reporting agency;
x Information we receive from you during interviews
We may disclose the following kinds of nonpublic personal information about you:
x Information we receive from you on intake forms, applications or other forms, such as name, address, social
security number, income, age, assets, family size, ethnicity, and other information from the intake
form/application;
x Information about your transactions with us, our affiliates, or others such as your payment history or amounts
due to us;
x Information we receive from a consumer reporting agency such as your credit history;
x Information gathered from interviews with us, such as family size
Habitat for Humanity of Lee and Hendry Counties, Inc., employees and volunteers are subject to a written policy
regarding confidentiality and access to applicant data is restricted to staff and volunteers on an as-needed basis.
Information is used for lawful business purposes and is never shared with third parties without your consent, except as
permitted by law. As permitted by law, we may disclose nonpublic personal information about you to the following types
of third parties:
x Financial service providers, such as mortgage servicing agents or banks providing loan funding;
x Nonprofit organizations, public sector agencies or governments
We may also disclose nonpublic information about you to nonaffiliated third parties as permitted by law, in connection
with our normal operating practices.
We do not disclose any nonpublic personal information about you to anyone, except as permitted by law. We maintain
physical, electronic and procedural safeguards that comply with federal regulations to guard your nonpublic personal
information.
I acknowledge that I have received a copy of Habitat for Humanity of Lee and Hendry Counties, Inc. Privacy Statement
and Notice.
Client Signature Date Client Signature Date
____________________________________ _______________________________________
Print Name __________________________ Print Name ______________________________
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