DFM Intake Forms | Dominion Financial Management, Inc.

Instructions:

Please complete this form before your session or class with Dominion Financial Management, Inc. You’ll be able to upload your photo ID, review disclosures and other documents, and submit the form. For any questions, email [email protected].

Last Name *

Enter your last name

First Name *

Enter your first name

Street Address (Current) *

Please enter your Street Name and Number, e.g., 123 Main Street

City *

Please enter your City, e.g., Smyrna

State *

Tennessee
Other

Other State

Please enter your State, if other than Tennessee, e.g., Alabama

Zip Code *

Please enter your 5 digit Zip Code, e.g., 37167

County *

Enter the County, e.g., Rutherford, Davidson, etc.

Residency Status *

Date of Birth *

Last 4 Digits of Social Security Number *

Phone *

May we text you at this number? *

Yes
No

We will text to remind you about upcoming appointments and for you to communicate with your financial coach. We will not sell your information to any other third party. You may opt out at any time by texting STOP.

Email *

Gender *

Male
Female
Chose not to disclose

Ethnicity *

Hispanic
Not Hispanic
Chose not to respond

Race *

Please check only one.

Multi-Race?

Yes, I want to add an additional race

Race (Second)

Please add only one additional race.

Limited English Proficiency Status *

I am limited in my English proficiency.
I am not limited in my English proficiency.
Chose not to respond.

Please check only one.

Marital Status *

Please check only one.

Highest Education *

Please check only one.

Head of Household Type *

US Veteran *

Yes
No

Disabled *

Yes
No

Owned Home is Last 3 Years *

Yes
No

Co-Applicant? *

Yes
No

Co-Applicant Last Name *

Enter the Co-Applicant's last name

Co-Applicant First Name *

Enter your Co-Applicant's first name

Is the Co-Applicant Address the Same? *

Yes
No

Choose Yes if the Applicant and Co-Applicant have the same address. Choose No if the Applicant and Co-Applicant have a different address.

Co-Applicant Street Address (Current) *

Please enter your Co-Applicant's Street Name and Number, e.g., 123 Main Street If Same, Enter "Same"

Co-Applicant City *

Please enter your Co-Applicant's City, e.g., Smyrna

Co-Applicant State *

Please enter your Co-Applicant's Full State Name, e.g., Tennessee

Co-Applicant's Zip Code *

Please enter your Co-Applicant's 5 digit Zip Code, e.g., 37167

Co-Applicant County *

Enter the Co-Applicant's County, e.g., Rutherford, Davidson, etc.

Co-Applicant Residency Status *

Co-Applicant Date of Birth *

Co-Applicant Last 4 Digits of Social Security Number *

Co-Applicant Phone *

Co Applicant Email *

Co-Applicant Gender *

Male
Female
Chose not to disclose

Co-Applicant Ethnicity *

Hispanic
Not Hispanic
Chose not to respond

Co-Applicant Race *

Please check only one.

Co-Applicant Multi-Race?

Yes, I want to add an additional race

Co-Applicant Race (Second)

Please add only one additional race.

Co-Applicant Marital Status *

Please check only one.

Co-Applicant Highest Education *

Please check only one.

Co-Applicant US Veteran *

Yes
No

Co-Applicant Disabled *

Yes
No

Owned Home is Last 3 Years (copy) *

Yes
No

Number in Household *

Number of Dependents *

If none, enter 0

TOTAL Gross MONTHLY Income (Household) *

Before Taxes - Include ALL income sources.

TOTAL Gross ANNUAL Income (Household) *

Before Taxes - Include ALL income sources.

Referred By *

How did you hear about us?

Referral Name *

Service Received Today *

Class
One-on-One Session

Class *

Please pick the best choice to describe the class you received today.

One-on-One Session *

Online Homebuyer Education Follow/up (Phone)
RealHelp Financial Coaching - Homebuying
RealHelp Financial Coaching - Rental
RealHelp Financial Coaching - Homeless Prevention
RealHelp Financial Coaching - Foreclosure Prevention
RealHelp Financial Coaching - Budget, Credit, Debt
Other Session

Please pick the best choice to describe the session you received today.

Service Format *

Phone
Virtual
In-Person

Service Date *

MM/DD/YYYY

Photo ID Copy Upload

Click or drag a file to this area to upload.

Co-Applicant Photo ID Copy Upload

Click or drag a file to this area to upload.

Survey Questions

This information is collected for statistical purposes only. Choose the answer that best describes your entire household.

Employment *

Full Time (30+ Hours Per Week)
Part Time (1-29 Hours Per Week)
Unemployed and Looking For Work
Other

Please choose all that apply

Do you use a Written Budget? *

Yes, all the time
Yes, some of the time
No, not at all

Do you carry balance(s) on your credit card(s)? *

Yes, I have carried a balance
No, I pay them off every month
N/A, I do not have credit cards

Total Savings? *

None
$1-$5,000
$5,001-$10,000
Over $10,000

Credit Score? *

Total Debt? *

Debt includes credit cards, auto loans, student loans, personal loans, etc.

Do you feel you have control over your finances? *

Completely controlled
Somewhat controlled
Not at all controlled

Do you feel capable of surviving a financial setback? *

Completely capable
Somewhat capable
Not at all capable

Are you on track to meet your financial goals? *

Completely on track
Somewhat on track
Not at all on track

Do you have the financial confidence to make wise financial choices? *

Completely confident
Somewhat confident
Not at all confident

Privacy Policy *

I/We have read and understand the <a href="https://www.dominionfinancial.org/privacy-policy">privacy policy and other disclosures</a> of Dominion Financial Management, Inc.

HUD Disclosures *

I/We have read and understand the <a href=" https://dominionfinancial.org/hud-disclosures/">Home Inspection and Lead-Based Paint Disclosures</a> We are interested in purchasing a home at this time.
Not Applicable (N/A) - I/We are not interested in purchasing a home at this time.

Fair Housing Policy *

I/We have read and understand the <a href="https://dominionfinancial.org/wp-content/uploads/2024/06/Fair-Housing-Statement.pdf">Fair Housing Policy</a> of Dominion Financial Management, Inc.

GDPR Agreement *

I/We consent to having this website store my submitted information for reporting and response purposes only.

Accommodations - We are prepared to provide vital documents and information in alternative formats, provide accessibility features or make alternate accommodations for persons with disabilities, in accordance with section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), 24 CFR parts 8 and 9, and the American with Disabilities Act (42 U.S.C. 12101 et seq).

Signature *

Clear Signature