Philadelphia Council for Community Advancement (PCCA)

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PCCA is a 501(c)(3) not-for-profit organization.

[ * = required information ]

Client Name: *

Age:

Home Phone:

Work Phone:

Email Address: *

Spouse:

Age:

Home Phone:

Work Phone:

Other:

Address:

City:

State:

Zip:

Gender/age of Dependents/Total household

Combined Annual Household Income

Yearly $:
Monthly $:

Income Sources:

TYPE OF SERVICES

Mortgage Default

Mortgage Co. Name:

Phone:

Contact Name:

Loan Number

Loan Type

	Conv. /VA/Act 91
	FHA Assignement

Number of month due ?

Reg. Payment amount ?

General

	Utilities
	Home Repairs
	Housing Complaint
	Refinance

Preparation for Home Buying

Credit Score

Rental Delinquency

Rental Payment $

Number of Payments Due

Reverse Mortgage Educ.

Date of Birth:

Property Value $

Mortgage Balance $

Write in Appropiate Income Category (See chart below)

Family size	Very Low		Low		Moderate	Middle
	25%	30%	50%	60%	80%	120%
1	12,625	15,150	25,250	30,300	40,400	60,600
2	14,425	17,300	28,850	34,620	46,150	69,240
3	16,225	19,500	32,450	38,940	51,950	77,880
4	18,025	21,650	36,050	43,260	57,700	86,520
5	19,475	23,400	38,950	46,740	62,300	93,480
6	20,900	25,100	41,800	50,160	66,950	100,320
7	22,350	26,850	44,700	53,640	71,550	107,280
8	23,800	28,600	47,600	57,120	76,150	114,240

Revised March 2006

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