Request For Counseling Intake Form 

Requestor's Information

Full Name:
Company Name:
Fax Number:
Phone Number:

Mailing Address:
City State Zip
Email Address:
HUD Required Information
Client First Name
Client Last Name
Client's DOB:
HUD Required
Client's SSN: *
HUD Required
Client's Race:

Spouse's Name:

Spouse's DOB:
HUD Required
Spouse's SSN *:
HUD Required
Phone Number:
Mailing Address:
City State Zip
Email Address:
Type of Counseling Requested
Buyer's Type of Payment for Counseling
Purchase Property Address:
City State Zip
Title Company:
Contact Phone#:
Closing Date:
Loan #:
Loan Amount:
Real Estate Agent:
* Social Security Numbers are optional and may be given to the counselor over the phone if preferred. (817) 346-9990 / (866) 279-4200


Ephram/Neal Enterprises, Inc.

2401 Scott Ave., Ste. 120   Fort Worth, TX   76103
OFC: (817) 346-9990 or Toll: (866) 279-4200  / FAX: (817) 423-4207