Intake Form | Martindale Brightwood CDC

Today's Date

MM slash DD slash YYYY

Name*

First Last

Email*

Phone*

Preferred Method of Contact*

Please select all that apply.

Phone

Letter

Other

List other preferred method of contact

Address*

Street Address City State / Province / Region ZIP / Postal Code

Date of Birth*

Month

Day

Year

Gender*

Female

Male

Prefer not to answer

Race*

American Indian / Alaskan Native

Asian

Black / African American

Hispanic / Latino

Native Hawaiian / Other Pacific Islander

White

Other

Prefer not to answer

Marital Status*

Married

Domestic Partner

Single (never married)

Separated

Divorced

Widowed

Ethnicity*

Hispanic

Non-Hispanic

Prefer not to answer

Disability*

Yes

Prefer not to answer

Are you a Military Veteran?*

Yes

Prefer not to answer

Have you ever been convicted?*

Yes

Highest Level of Education?*

Less than High School

High School Diploma / GED

Some College

Technical School graduate or technical certification

Two-Year Degree

Four-Year Degree

Masters Degree

Doctorate Degree

Employment*

Full-time

Part-time

Self-employed

Retired

Unemployed

What is your gross annual income?*

Income Source*

Social Security

Pension/ Annuity

Interest/ Dividends

Earned Income from job(s)

Disability

Child Support

Other

What is your credit score?*

What is your household size?*

Number of people including yourself.

Household Members Names, Relationship, Birthday, Education, & Employment Status*

Section Break

MBCDC Program Interest*

Please check all that apply.

Community Education

Community Maintenance

Employment Services (Youth and Adult)

Financial Literacy

Homeownership

Home Repair

Individual Development Account (Savings Program)

Jumpstart

Small Business

Volunteer

Other

List Other Program Interest Below (Program name)

Small Business

Business Name*

What is your product or service?*

Business Annual Income*

How many employees?*

Is your business Minority Certified with the City of Indianapolis?

Yes

Is your business Minority Certified with the State of Indiana?

Yes

Do you have insurance?

Yes

Are you bonded?

Yes

Do you have a business license?

Yes

N/A

Additional Information

Home Repair

How many years have you owned your home?*

Have you received FHLBI grant funds in the past 5 years?*

Yes

I don't know

Have you applied for FHLBI funds at another agency?*

Yes

I don't know

Are your mortgage payments current?*

Yes

I don't know

Do you have homeowners insurance?*

Yes

I don't know

Are your property taxes paid and current?*

Yes

I don't know

Is there anyone on the DEED of the home that is not living in the home?*

Yes

I don't know

If yes, what is their relationship to you?*

I hereby transfer and grant the Martindale Brightwood Community Development Corporation ("MBCDC") the exclusive right to use and authorize others to use all or any part of my (his/her) interview/photograph/video in related media such as books, newsletters, flyers, magazines, journals, pamphlets, electronic (Internet) and other written and video formats. I also hereby release MBCDC and its directors, members, trustees, officers, employees, and agents from any and all claims, demands, causes of action and suites, including but not limited to, claims for invasion of privacy, defamation, breach of contract or other breach of duty arising out of of in connection with the use of this interview, photo, or video.*

Agree

I hereby certify that the information included on this form is correct to the best of my knowledge and that such information may be subject to verification by representatives of Martindale Brightwood CDC for purposes of meeting requirements for a program.*

Agree