MOR-06 PHFA Authorization, Disclosure, Privacy Statement (3-in-1)


Form 6 of 9

Urban League of Philadelphia

Counseling Services Authorization

My personal information and counseling services By signing this form I agree to share my personal financial and other private information. Signing this form also allows lenders and the Counseling Agency to discuss my accounts, credit, and finances, and to share my nonpublic personal information, described in the Privacy Policy provided with this authorization. I understand that funders provide grants to make the counseling services possible, and that the Counseling Agency shares my information with these funders. These funders review Counseling Agency files, including my file, and may contact me to evaluate the counseling services that I receive. I authorize my Counselor and the Counseling Agency to negotiate for me. The counseling services are offered free of charge, and neither the Counselor, nor the Counseling Agency, guarantees any result or outcome. I may be referred to other housing agencies for their services. I am not obligated to accept services or products from the Counseling Agency, its partners, or any organization I am referred to. I understand that my Counselor cannot offer me legal or other professional advice or representation. If I need legal or other professional services I can ask my Counselor for information about referral services. Counseling Services Checklist Client must initial all items that are applicable. I understand that the counselor will discuss my budget with me and I will receive a copy of my Budget I understand that the counselor will discuss my Action Plan with me and I will receive a copy of my Action Plan I understand the counselor will explain the next steps needed to reach my financial goal to my satisfaction Homebuyer Counseling Homebuyer Education Homeowner Counseling Homeowner Education Delinquency and Default Counseling Delinquency and Default Education Reverse Mortgage Counseling Fair Housing Education Tenant Counseling Homelessness and Displacement Counseling I want to buy a home in the next six (6) months I want to buy a home, but not in the next six (6) months Other programs, services, or products: I have received the HUD forms: “Ten Important Questions to Ask Your Home Inspector” & “For Your Protection: Get a Home InspectionCounseling Agency Information (optional) Counselor Name: Counselor Phone: Counseling Agency: Urban League of Philadelphia Counseling Agency Email: info@urbanleaguephila.org Counseling Agency Fax: 215.545.2631

Privacy Policy

This Counseling Agency respects the privacy of the people that come to us for assistance. We understand that the matters you discuss with us are very personal. All spoken and written information shared with us will be managed with our legal and ethical obligations to you taken into consideration. We will not sell your personal information and we only share it to provide you with counseling services. Your “nonpublic personal information” (including total debt information, income, living expenses, and personal information concerning your financial circumstances) will be shared with creditors, funders, and others only after you sign the Counseling Services Authorization. We may also collect, use, and share anonymous aggregated case file information to evaluate our services, to gather valuable research information, and to design future programs. Types of Information That We Gather About You:
  • Spoken or written information on applications and other documents, such as your name, address, social security number, assets, and income;
  • Information about your transactions with us, your creditors, or others, such as your account balance, payment history, parties to transactions and credit card usage; and
  • Information we receive from a credit reporting agency, such as your credit history.
How We Use Your Information:
  • If you do not opt-out we may share information that we collect about you with your creditors or others if we think it would be helpful to you, would help us counsel you, or when required by funders that make our services possible.
  • We may share information about you to anyone as permitted or as required by law (e.g., if a Court requires us to provide it with documents).
  • Within our organization, we restrict access to your information to those employees who need to know that information to provide services to you. We maintain physical, electronic, and procedural safeguards to protect your information as required by federal and state law.
Client Authorization By signing below I authorize my employers, lenders, creditors, servicers, and others to share personal and financial information with my Counselor and the Counseling Agency. I authorize my Counselor and the Counseling Agency to collect information about my accounts and to share this information with others, including funders, as needed to provide counseling services, to seek assistance from programs, or for related products and services. I authorize funders to contact me to evaluate programs that I participate in. Client Name(s) 1. 2.

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Signature Certificate
Document name: MOR-06 PHFA Authorization, Disclosure, Privacy Statement (3-in-1)
lock iconUnique Document ID: 2e0816d9a3910ff39e84d004e5e08f60afe49a39
Timestamp Audit
May 15, 2019 10:03 pm EDTMOR-06 PHFA Authorization, Disclosure, Privacy Statement (3-in-1) Uploaded by David Bruggink - david.bruggink@gmail.com IP 192.168.95.1, 172.17.0.1
July 3, 2019 10:08 pm EDTDeserie Hill - dhill@urbanleaguephila.org added by - as a CC'd Recipient Ip: 192.168.95.1, 172.17.0.1
July 5, 2019 10:08 pm EDTULP Housing - housing@urbanleaguephila.org added by - as a CC'd Recipient Ip: 192.168.95.1, 172.17.0.1
July 6, 2019 12:38 pm EDTULP Housing - housing@urbanleaguephila.org added by - as a CC'd Recipient Ip: 192.168.95.1, 172.17.0.1
July 6, 2019 10:19 pm EDTULP Housing - housing@urbanleaguephila.org added by - as a CC'd Recipient Ip: 192.168.95.1, 172.17.0.1