Coastal Housing Center Main Office

768 Virginia Ave Suite A 605 SE Kane St.

North Bend, OR 97459 Roseburg, OR 97470
Phone: 541-756-1000 Phone: 541-673-4909

Dear Homeowner,

You are not alone:

Thank you for contacting NeighborWorks Umpqua, we understand that no one enters into their mortgage loan
expecting to have trouble making their payments. Life changes and unexpected hardships can suddenly happen,
catching even the most prepared off guard. Dealing with being in default with your mortgage can be a difficult
life experience but you don't have to go through it alone.

Who we are:
o NeighborWorks Umpqua was established in 1991 and provides educational classes, housing rehab
opportunities, and counseling services throughout Coos, Curry, Douglas, Jackson and Josephine Counties.
o In response to the foreclosure crisis NeighborWorks Umpqua became a part of the National Foreclosure
Mitigation Counseling Program in 2008. In 2012 NeighborWorks Umpqua became part of the Oregon
Foreclosure Avoidance Program. Which we currently participate in.

Key points to know:

• There is no cost to you for any of our Default Intervention Services.
• To follow is a checklist and all the necessary forms you will need to get you started, if you have any
questions, please contact our Intake Specialist.
• Once a complete intake packet and all supporting documentation has been submitted to our office, it will be
reviewed for completeness and then assigned to a counselor. Please use the attached Document Checklist.
• After the counselor has completed a review of your documentation and done an analysis of your situation,
you will be contacted by our office to schedule your first appointment with your counselor.
• It is very important that you establish a relationship and communicate with our office throughout this
process.
• Failure to provide all requested documentation, or respond to follow up requests, will result in your file
being closed.

We look forward to working with you,

- NeighborWorks Umpqua Housing Stability Staff

Date Revised: 01/13/2022

Equal Housing Opportunity and Equal Housing Lender

www.nwumpqua.org | CCB# 15199 | NMLS# 255912

 Coastal Housing Center Main Office
768 Virginia Ave Suite A 605 SE Kane St.
North Bend, OR 97459 Roseburg, OR 97470
Phone: 541-756-1000 Phone: 541-673-4909

Client Bill of Rights and Responsibilities

NeighborWorks Umpqua is committed to providing you with high quality professional services. NeighborWorks
Umpqua does not discriminate in the selection and participation of clients in its programs with respect to race,
religion, color, gender, age, national origin, or disability.

Client Rights

o To be treated with dignity and respect

o To have your information treated with confidentiality
o To be actively involved in any plan developed for you
o To have program requirements explained to you
o To have any complaints addressed in a timely manner
o To ask questions and be informed of your rights
o To discontinue your relationship with us at anytime
o To be presented with all options and programs available to you

Client Responsibilities

 To speak in a respectful manner to have your concerns addressed

 To provide accurate up to date information to the person(s) assisting you
 To understand the requirements of the program(s) you are participating in and to fulfill them promptly
 To ask questions when you need clarification
 To keep your appointments and when unable to do so provide 24 hrs. advance notice
 To arrive on time for your appointments
 To provide all requested documentation by deadline
 To maintain active communication with NeighborWorks Umpqua staff

Date Revised: 01/13/2022

Equal Housing Opportunity and Equal Housing Lender

www.nwumpqua.org | CCB# 15199 | NMLS# 255912

 Coastal Housing Center Main Office
768 Virginia Ave Suite A 605 SE Kane St.
North Bend, OR 97459 Roseburg, OR 97470
Phone: 541-756-1000 Phone: 541-673-4909

Documentation Checklist
NeighborWorks Umpqua cannot process your application and schedule your appointment with a counselor
without all the required documentation. If you have questions about what is being asked of you, please reach
out to your Intake Specialist

NeighborWorks Umpqua Forms:

□ Intake Form
□ Default Intervention Application
□ Referral For Translation Services Form
□ Client/Counselor Agreement
□ Disclosure and Authorization to Release Information
□ Credit Report Authorization Form
□ Privacy Policy and Practices
□ Personal Monthly Budget
□ Expense Priority Wheel

Personal Documentation (Single Sided Copies Only):

□ Mortgage Note and/or Deed of Trust All pages
□ Mortgage Statements Most recent, ALL pages for ALL Mortgages
□ Most Recent Letter(s) from your lender regarding your delinquency - within last 90 days
□ Utility Bill Most recent, needed to prove residency
□ Monthly Bank Statements Last 2 Months, for ALL accounts, ALL pages
□ Federal Tax Returns Last 2 Years, 1040 Form must be signed & dated by all borrowers
□ Valid Photo ID
□ 1 Month Proof of Income(s)
□ Paystubs for the last 30 days
□ Social Security Award Letter
□ Pension Award Letter
□ Unemployment Benefit Statement
□ Rental Income: Rental Agreement, YTD Profit and Loss Statement (PNL)
□ Self-Employed: YTD PNL, Last 2 Months Business Bank Statements, Last 2 Years Business Taxes
□ SNAP: Award Letter, 12 Months Proof of Receipt
□ Other Income: ___________________________

Date Revised: 01/13/2022

Equal Housing Opportunity and Equal Housing Lender

www.nwumpqua.org | CCB# 15199 | NMLS# 255912

 Roseburg Office: 605 SE Kane St, Roseburg OR 97470 Ph: 541-673-4909 Fax: 541-673-5023
North Bend Office: 1984 Sherman Ave, North Bend OR 97459 Ph: 541-756-1000 Fax: 866-572-1970
www.nwumpqua.org

APPLICANT 1 DEFAULT INTERVENTION INTAKE FORM Please Print Clearly

Name:
First Middle Initial Last

Address:
Street Address PO Box

City State Zip County

Home Ph: Work Ph: Cell Ph: Other Ph:

Email: Preferred Language:

Birth Date: Last 4 digits of Social Security Number:

Gender: Male Female Other / Non-Conforming

How did you hear about us?

Please Check All That Apply

Race: Alaskan Native / American Indian Asian Black / African American
Native Hawaiian / Other Pacific Islander White More than one race
Hispanic Non-Hispanic Chose not to respond

Please Check Highest Level of Education Completed

Education: Graduate School College Vocational Junior College
High School / GED Junior High School Primary Other
Unknown None Chose not to respond

Please Check
Marital Status: Single Adult Married w/ Children Married w/o Children
Divorced Separated Widowed
Unrelated Adults Unknown Chose not to respond

Please Check All That Apply

Sources of Income: Employment Self Employment SSI/SSD Pension
Unemployment Rental Income Alimony / Child Support SNAP
Other: _________________________________________

Please Put Annual Gross Income for Entire Household

Total Household Gross Annual Income: $_______________________________

Date Revised - 01/13/2022 Page 1 of 3

APPLICANT 1 CONT. DEFAULT INTERVENTION INTAKE FORM Please Print Clearly
Please Check
Type of Housing: Single Family Condominium Apartment
Mobile In Park Mobile On Land Rental
Multi-Family (2-4 units) Chose not to respond
Please Answer All Questions
Were you born in the United States? Yes No Are you a Veteran? Yes No

Are you Disabled? Yes No Disabled Dependents? Yes No

Is Applicant 1 Head of Household? Yes No Do you live in a Rural Area? Yes No

Are you English Proficient? Yes No Are you in the Active Military? Yes No

Total Number of People Living in Household?

Ages of Dependents: _______ _______ _______ _______ _______ _______ _______ _______ _______ _______

APPLICANT 1 EMPLOYMENT Please Print Clearly

Employer: Hire Date:

Your Title: Business Type:

Monthly Gross Income: Monthly Net Income:

Paid: Hourly Weekly Bi-Weekly Semi-Monthly Monthly

APPLICANT 2 Please Print Clearly

Name:
First Middle Initial Last

Home Ph: Work Ph: Cell Ph: Other Ph:

Email: Preferred Language:

Birth Date: Last 4 digits of Social Security Number:

Gender: Male Female Other / Non-Conforming

Please Check All That Apply

Race: Alaskan Native / American Indian Asian Black / African American
Native Hawaiian / Other Pacific Islander White More than one race
Hispanic Non-Hispanic Chose not to respond

Please Check Highest Level of Education Completed

Education: Graduate School College Vocational Junior College
High School / GED Junior High School Primary Other
Unknown None Chose not to respond

Date Revised - 01/13/2022 Page 2 of 3

APPLICANT 2 CONT. DEFAULT INTERVENTION INTAKE FORM Please Print Clearly
Please Check
Marital Status: Single Adult Married w/ Children Married w/o Children
Divorced Separated Widowed
Unrelated Adults Unknown Chose not to respond

Please Circle All That Apply

Sources of Income: Employment Self Employment SSI/SSD Pension
Unemployment Rental Income Alimony / Child Support SNAP
Other: _________________________________________

Please Circle All That Apply

Relationship to Spouse / Partner Sibling Employer
Applicant 1: Friend Parent Other: ____________________________________

Please Answer All Questions

Were you born in the United States? Yes No Are you a Veteran? Yes No

Are you Disabled? Yes No Disabled Dependents? Yes No

Are you in the Active Military? Yes No Are you English Proficient? Yes No

APPLICANT 2 EMPLOYMENT Please Print Clearly

Employer: Hire Date:

Your Title: Business Type:

Monthly Gross Income: Monthly Net Income:

Paid: Hourly Weekly Bi-Weekly Semi-Monthly Monthly

AUTHORIZATION Please Print Clearly

I authorize NeighborWorks Umpqua to:

Obtain a copy of the Final Closing Disclosure, Appraisal, and Real Estate Note(s) when I purchase/refinance a home from the lender
who made me a loan and/or Title Company that closed the loan.

I hereby verify this information to be true and accurate to the best of my knowledge, and if asked can prove accuracy of the information. I
understand the fee I am paying is non-refundable. I identify the person(s) signing the registration form to be the customer(s) receiving services
from NeighborWorks Umpqua.

Applicant 1 Date

Applicant 2 Date

Date Revised - 01/13/2022 Page 3 of 3

 Default Intervention Application
Client Information
What is the current status of your credit? Excellent Good Bad Do not have any Do not know

Has your income changed since you originally got your current mortgage loan? Yes ( Increase or Decrease) No

What is your ideal situation for your home? Keep Sell Unsure

Was the reason for default realted to COVID19? Yes No

Are you still living in your home? Yes No

Financial Situation
Can you document your child support/alimony income? Yes No If yes, how long will it continue?

Are you currently in Chapter 13 Bankruptcy? Yes No

If yes, when did it begin? If yes, when will it be paid out?

If yes, how much is the payment? $

Have you had a Chapter 7 Bankruptcy? Yes No If yes, when was it discharged?

Are there any non-tax liens or judgments' against you or your property? Yes No
If yes, who is the lien holder?
If yes, what is the amount of the lien/judgment? $

Do you have any collections? Yes No

If yes, who is the collection agency?
If yes, what is the amount of the collection? $

Any Unpaid Federal Debts, Liens, or Unpaid Taxes? Yes No

If Yes, how much? $

Current Total Debt on Property $

Estimated Property Value $

Scam Information
Has anyone offered to modify or refinance your mortgage, either directly, through advertising, by mail or by any Yes No
other means such as a flyer?

Have you ever been guaranteed a loan modification, or asked to do any of the following:

Sign a contract Sign over the title to your property Redirect your mortgage payments
Told you to stop making your loan payments Pay a fee for assistance or counseling

Date Revised - 01/13/2022

 Coastal Housing Center Main Office
768 Virginia Ave Suite A 605 SE Kane St.
North Bend, OR 97459 Roseburg, OR 97470
Phone: 541-756-1000 Phone: 541-673-4909

Referral For Translation Services

For clients requiring any non-English speaking services the following list of resources is being made available
to you:

ALTA Language Services, Inc

Tel: (404) 920-3800
Fax: (404) 920-3801
www.altalang.com

By signing below, I am acknowledging that this list has been provided to me.

_________________________________________ _________________
Homeowner Signature Date

_________________________________________ _________________
Counselor Signature Date

Date Revised: 01/13/2022

Equal Housing Opportunity and Equal Housing Lender

www.nwumpqua.org | CCB# 15199 | NMLS# 255912

 Coastal Housing Center Main Office
768 Virginia Ave Suite A 605 SE Kane St.
North Bend, OR 97459 Roseburg, OR 97470
Phone: 541-756-1000 Phone: 541-673-4909

Client/Counselor Agreement

NeighborWorks Umpqua and its staff agree to provide the following services:
▬ Analysis of the mortgage default, including the amount and cause of default.
▬ Presentation and explanation of reasonable options available to the homeowner.
▬ Assistance communicating with the mortgage servicer and other creditors.
▬ Timely completion of promised action.
▬ Explanation of collection and foreclosure process.
▬ Identification of assistance resources.
▬ Referrals to needed resources.
▬ Confidentiality, honesty, respect, and professionalism in all services.
▬ Guidance in developing a realistic spending plan, based on homeowner decisions and choices in spending.
▬ Assistance in escalating any legitimate issues with the mortgage company. (This does not include
assistance in escalation of cases where the homeowner disagrees with the mortgage company's decision
but there is no factual basis for escalation)
▬ Counselors may answer questions and provide information but will not give legal advice. If I want legal
advice, recommendation will be that I seek legal assistance from the appropriate entities.

I/We, ________________________________________ agree to the following terms of services:

 I/We will always provide honest and complete information to my/our counselor, whether verbally or in
writing.
 I/We will provide all necessary documentation and follow-up information within the timeframe requested.
 I/We will be on time for appointments and understand that if I/we are late for an appointment, the
appointment will still end at the scheduled time.
 I/We will call within 24 hours of a scheduled appointment if I/we will be unable to attend an appointment.
 I/We will understand that breaking this agreement may cause the counseling organization to sever its
service assistance to me/us.
 I/We will be honest, respectful, and courteous in all forms of communication with staff.
 I/We will contact the counselor when the mortgage company contacts us with questions, document
requests, or loss mitigation offers. (Such as a Trial Period Plan or Modification)

Date Revised: 01/13/2022

Equal Housing Opportunity and Equal Housing Lender

www.nwumpqua.org | CCB# 15199 | NMLS# 255912

 Coastal Housing Center Main Office
768 Virginia Ave Suite A 605 SE Kane St.
North Bend, OR 97459 Roseburg, OR 97470
Phone: 541-756-1000 Phone: 541-673-4909

I give NeighborWorks Umpqua permission to use my name in any current and future publications or reporting.
Furthermore, since NeighborWorks Umpqua is a non-profit organization, I hereby release, hold harmless, and
waive all claims associated with these publications and marketing materials which I may have against
NeighborWorks Umpqua and its employees.

_________________________________________ _________________
Homeowner Signature Date

_________________________________________ _________________
Homeowner Signature Date

_________________________________________ _________________
Counselor Signature Date

Date Revised: 01/13/2022

Equal Housing Opportunity and Equal Housing Lender

www.nwumpqua.org | CCB# 15199 | NMLS# 255912

 Coastal Housing Center Main Office
768 Virginia Ave Suite A 605 SE Kane St.
North Bend, OR 97459 Roseburg, OR 97470
Phone: 541-756-1000 Phone: 541-673-4909

Disclosure and Authorization to Release Information

In order to provide the best possible services, it may be necessary for NeighborWorks Umpqua to
communicate with individuals or agencies that may be able to assist you. By signing below, you acknowledge
your understanding of NeighborWorks Umpqua policies.

I/We understand (NeighborWorks Umpqua) provides housing counseling after which I/we will receive a
written action plan consisting of recommendations for handling my/our situation, possibly including referrals
to other housing agencies as appropriate.

______ I/We Choose to Opt Out

I/We understand NeighborWorks Umpqua receives Congressional funds through the Housing Stability
Counseling Program (HSCP), Homeownership Assistance Program (HOAP), and Housing and Urban
Development (HUD) programs and, as such, is required to share some of my/our personal information with
HSCP, HOAP and HUD program administration or their agents for purposes of program monitoring,
compliance, and evaluation.

______ I/We Choose to Opt Out

I/We give permission for HSCP, HOAP and HUD program administrators and/or their agents to follow-up with
me/us between now and June 30, 2026, for the purposes of program evaluation.

______ I/We Choose to Opt Out

I/We understand NeighborWorks Umpqua provides information and education on numerous loan products
and housing programs, and I/we further understand that the housing counseling I/we receive from
NeighborWorks Umpqua in no way obligates me/us to choose any of these particular loan products or housing
programs.

______ I/We Choose to Opt Out

I/We release NeighborWorks Umpqua’s Board of Directors, officers, and employees from any and all claims,
demands and liability of any sort resulting from the release of such information.

______ I/We Choose to Opt Out

Date Revised: 01/26/2022

Equal Housing Opportunity and Equal Housing Lender

www.nwumpqua.org | CCB# 15199 | NMLS# 255912

 Coastal Housing Center Main Office
768 Virginia Ave Suite A 605 SE Kane St.
North Bend, OR 97459 Roseburg, OR 97470
Phone: 541-756-1000 Phone: 541-673-4909

I/We understand NeighborWorks Umpqua provides homeownership education and counseling, individual
development accounts, affordable housing opportunities, foreclosure intervention counseling, down payment
assistance grants and/or loans, and low-income housing rehab assistance. NeighborWorks Umpqua partners
with for-profit and non-profit organizations, which may include financial institutions, realtors, lenders,
contractors, title companies and other community entitles.

I/We understand a counselor may answer questions and provide me information, but not give legal advice. If
I/we want legal advice, I/we will be referred for appropriate assistance.

I/We may be referred to other housing services of the organization or other agency or agencies as appropriate
that may be able to assist with concerns that have been identified. I/We understand that I/we am/are not
obligated to use any of the services offered to me/us.

I/We acknowledge that I/we have received a copy of (NeighborWorks Umpqua) privacy policy.

By signing this form, you acknowledge that you are entering into a counseling agreement with NeighborWorks
Umpqua. We will make all attempts to resolve your situation and to guide you through the process of
reviewing your options. This is in no way a guarantee of results and NeighborWorks Umpqua is in no way
legally responsible for the outcome of this counseling. By not signing this form, you understand that
NeighborWorks Umpqua may not perform any default counseling services on your behalf.

This consent to disclose may be revoked by me/us at any time by written, signed, and dated notice to
NeighborWorks Umpqua that consent is revoked.

_________________________________________ _________________
Homeowner Signature Date

_________________________________________ _________________
Homeowner Signature Date

Date Revised: 01/26/2022

Equal Housing Opportunity and Equal Housing Lender

www.nwumpqua.org | CCB# 15199 | NMLS# 255912

 Coastal Housing Center Main Office
768 Virginia Ave Suite A 605 SE Kane St.
North Bend, OR 97459 Roseburg, OR 97470
Phone: 541-756-1000 Phone: 541-673-4909

Credit Report Authorization Form

I hereby authorize and instruct NEIGHBORWORKS UMPQUA. (hereinafter “NEIGHBORWORKS UMPQUA”) to
obtain and review my credit report at the time of intake. My credit report will be obtained from a credit
reporting agency chosen by NEIGHBORWORKS UMPQUA. I understand and agree that NEIGHBORWORKS
UMPQUA intends to use the credit report for the purpose of evaluating my financial situation.

My signature below also authorizes the release to credit reporting agencies of financial or other information
that I have supplied to NEIGHBORWORKS UMPQUA in connection with such evaluation. Authorization is
further granted to the credit reporting agency to use a copy of this form to obtain any information the credit
reporting agency deems necessary to complete my credit report.

I understand that I may revoke my consent to these disclosures by notifying NEIGHBORWORKS UMPQUA in
writing.

I authorize NeighborWorks Umpqua to send me a copy of my credit report via the following methods (check
all that apply):
- US Mail
- Encrypted Email
- Fax
*Please note: if no box is checked, US Mail will be the default method of delivery.

Residential Address: _________________________________________________________________________

Applicant 1 SSN: ____________________ Applicant 1 Date of Birth: _____________________

Applicant 2 SSN: ____________________ Applicant 2 Date of Birth: _____________________

_________________________________________ __________________________________________
Full Legal Name Signature Date

_________________________________________ __________________________________________
Full Legal Name Signature Date

Date Revised: 01/13/2022

Equal Housing Opportunity and Equal Housing Lender

www.nwumpqua.org | CCB# 15199 | NMLS# 255912

 Coastal Housing Center Main Office
768 Virginia Ave Suite A 605 SE Kane St.
North Bend, OR 97459 Roseburg, OR 97470
Phone: 541-756-1000 Phone: 541-673-4909

Privacy Policy and Practices of NeighborWorks Umpqua

We at NeighborWorks Umpqua value your trust and are committed to the responsible management, use and
protection of personal information. This notice describes our policy regarding the collection and disclosure of
personal information. Personal information, as used in this office, means information that identifies an
individual personally and is not otherwise publicly available information. This includes personal financial
information such as credit history, income, employment history, financial assets, bank account information
and financial debts. It also includes your social security number and other information you have provided us
on any applications or forms that you have completed.

Information We Collect
We collect personal information to support our lending operations, counseling, services, and to aid you in
shopping for and obtaining a home mortgage from a conventional lender. We collect personal information
about you from the following sources:
 Information we receive from you on applications or other forms,
 Information about your transactions with us, our affiliates, or others,
 Information we receive from a consumer reporting agency, and
 Information we receive from personal and employment references.
Information We Disclose
We may disclose the following kinds of personal information about you:
 Information we receive from you on applications or other forms, such as your name, address, social
security number, employer, occupation, assets, debts, and income.
 Information about your transactions with us, our affiliates, or others, such as your account balance,
payment history and parties to your transactions; and
 Information we receive from a consumer reporting agency, such as your credit bureau reports, your credit
history and your creditworthiness.
To Whom Do We Disclose
We may disclose your personal information to the following types of unaffiliated third parties:
 Financial service providers, such as companies engaged in providing home mortgage or home equity loans,
 Others, such as nonprofit organizations involved in community development, but only for program review,
auditing, research, and oversight purposes.
We may also disclose personal information about you to third parties as permitted by law.
Prior to sharing personal information with unaffiliated third parties, except as described in this policy, we will
give you an opportunity to direct that such information is not disclosed.

Date Revised: 01/26/2022

Equal Housing Opportunity and Equal Housing Lender

www.nwumpqua.org | CCB# 15199 | NMLS# 255912

 Coastal Housing Center Main Office
768 Virginia Ave Suite A 605 SE Kane St.
North Bend, OR 97459 Roseburg, OR 97470
Phone: 541-756-1000 Phone: 541-673-4909

Confidentiality and Security

We restrict access to personal information about you to those of our employees who need to know that
information to provide products and services to you and to help them do their jobs. Which includes
underwriting and servicing of loans, making loan decisions, aiding you in obtaining loans from others, and
financial counseling. We maintain physical and electronic security procedures to safeguard the confidentiality
and integrity of personal information in our possession and to guard against unauthorized access. We use
locked files, user authentication and detection software to protect your information. Our safeguards comply
with federal regulations to guard your personal information.

I/We have read and understand the terms of the above policy:

_________________________________________ _________________
Homeowner Signature Date

_________________________________________ _________________
Homeowner Signature Date

Date Revised: 01/26/2022

Equal Housing Opportunity and Equal Housing Lender

www.nwumpqua.org | CCB# 15199 | NMLS# 255912

 Roseburg Office: 605 SE Kane St, Roseburg OR 97470 Ph: 541-673-4909 Fax: 541-673-5023
North Bend Office: 1984 Sherman Ave, North Bend OR 97459 Ph: 541-756-1000 Fax: 866-572-1970
www.nwumpqua.org

Personal Monthly Budget

Gross Income Net Income
Income Source Amount Income Source Amount

Total Monthly Gross Income: 0 Total Monthly Net Income: 0

Surplus/Deficit 0 Surplus/Deficit 0

HOUSING Amount DEBTS Amount SAVINGS Amount

First Mortgage Car Payment 1 College Fund
Second Mortgage Car Payment 2 Savings Account
Real Estate Taxes Credit Card 1 Retirement Account
Association Dues Credit Card 2 Subtotal 0
Rent Credit Card 3 Percentage of Budget: NaN
Repairs/Maintenance Credit Card 4 *10-15%
Subtotal 0 Credit Card 5 CHARITY Amount
Percentage of Budget: NaN Motorcycle Charity & Offerings
*25-35% Personal Loan Tithes
UTILITIES Amount RV Other: _____________
Cable Student Loan 1 Subtotal 0
Electricity Student Loan 2 Percentage of Budget: NaN
Gas Student Loan 3 *10-15%
Internet Student Loan 4 LEGAL Amount
Pellets Other: _____________ Attorney
Phone Other: _____________ Liens/Judgments
Trash Subtotal 0 Other: _____________
Water/Sewer Percentage of Budget: NaN Subtotal 0
Wood *5-10% Percentage of Budget: NaN
Subtotal 0 TAXES Amount *1-5%
Percentage of Budget: NaN Federal MEDICAL/HEALTH Amount
*5-10% State Dentist
TRANSPORTATION Amount Local Doctor Bills
Gas & Oil Subtotal 0 Medications
Repairs & Tires Percentage of Budget: NaN Optometrist
License & Taxes *1-5% Vitamins/Supplements
Car Replacement PERSONAL Amount Other: _____________
Other: _____________ Alimony Other: _____________
Subtotal 0 Baby Supplies Subtotal 0
Percentage of Budget: NaN Books/Supplies Percentage of Budget: NaN
*10-15% Child Care/Sitter *5-10%
INSURANCE Amount Child Support RECREATION Amount
Auto Insurance Cosmetics/Hair Care Entertainment
Disability Insurance Education/Tuition Vacation
Health Insurance Gifts (inc. Christmas) Subtotal 0
Homeowner Insurance Miscellaneous Percentage of Budget: NaN
Identity Theft Music/Technology *5-10%
Life Insurance Organization Dues CLOTHING Amount
Long-Term Care Pet Supplies Adults
Rental Insurance Pocket Money (Hers) Children
Other: _____________ Pocket Money (His) Cleaning/Laundry
Subtotal 0 Replace Furniture Subtotal 0
Percentage of Budget: NaN Subscriptions Percentage of Budget: NaN
*10-25% Toiletries *2-7%
FOOD Amount Other: _____________
Groceries Other: _____________ TOTAL EXPENSES 0
Dining out Subtotal 0
Other: _____________ Percentage of Budget: NaN
Subtotal 0 *5-10% *Recommended Percentages
Percentage of Budget: NaN
*10-25% Affordability Ratios
Housing Payment PITI Front-End Ratio Total Debt Back-End Ratio
0 NaN 0 NaN
Date Revised - 01/13/2022
 Satisfaction Wheel

Housing Food

Utilities
Income

Clothing Transportation

Mental Health
Employment

Physical Health Education/School

WHEEL INSTRUCTIONS:
The 10 sections in this Wheel represent the different areas of your life.

Taking the center of the wheel as zero and the outer edge as 10, please rank your level of satisfaction with each
area out of 10 by placing a dot in each category to show your level of satisfaction. Zero is least satisfied and 10 is
most satisfied. There is no limit to the amount of any number you assign to categories.

You are not rating the categories as 0-10, you are rating each category separate from the others.

Date Revised: 01/10/2022