Screening/Participation Instruments

OMB No. 1505-XXXX

Participant Questionnaire

Thank you for agreeing to meet with us today. Before we begin our work, we ask that you take a moment to fill out a brief questionnaire. We will use this information to help us report our findings to the Consumer Financial Protection Bureau (CFPB). We will not use your name in our reports or any other identifying information as part of this project. Please check the appropriate boxes.

1. Are you a mortgage loan broker, lender, or loan originator?

• Yes

• No → Skip to Question 4

2. If yes, have you been in business for more than 4 years?

• Yes

• No

3. If yes, do you primarily serve minority populations?

• Yes, what population? ____________________________________________

• No

Mortgage brokers and lenders, please skip to Question 8

4. Have you bought or refinanced in the past 5 years?

• Yes, bought

• Yes, refinanced

• No→ Skip to Question 6

5. If yes, have you experienced a delinquency (foreclosure) or loan modification in the past five years?

• Yes

• No

6. Do you plan to buy or refinance in the next year?

• Yes

• No

7. Have you owned a home in the past?

• Yes

• No

8. What is your gender?

• Male

• Female

9. Are you married?

• Yes

• No

10. Are you of Hispanic or Latino origin (ethnicity):

• No, not of Hispanic or Latino origin

• Yes, Hispanic or Latino origin

• Cuban

• Mexican

• Puerto Rican

• South or Central American

• Another Hispanic or Latino Origin

11. What is your race? Please select one or more:

• White

• Black or African American

• Asian

• Native Hawaiian or other Pacific Islander

• American Indian or Alaska Native

12. What is your current age?

• 18–30

• 31–45

• 46-60

• Older than 60

13. What is the highest level of education you have completed?

• Less than high school, high school or GED

• Some college or a 2-year college program

• College graduate

• Additional education

14. What is your current household income?

• Less than $35k

• $35,001-70,000

• $70,001-125,000

• Over $125,000

15. The Consumer Financial Protection Bureau has posted mortgage disclosure forms on its website. Have you seen these forms or commented on them?

• Yes

• No

Thank you. You have finished the questionnaire.

An agency may not conduct or sponsor, and a person in not required to respond to, a collection of information unless the collection of information displays a valid control number assigned by the Office of Management and Budget (OMB). The OMB control number for this collection is XXXX–XXXX, expires XX/XX/XXXX. If you have any comments concerning this collection of information, please write to Kleimann Communication Group, 12600 St. James Road, Rockville, MD 20850.