Screening/Participation Instruments

OMB No. 1505-0233

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 worked in this 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 9

4. Would you be involved in the decision about choosing a mortgage loan if you were buying a house or refinancing a current loan?

• Yes, I participate in the decision-making

No→ Terminate. I am sorry, but the focus of our study requires us to get information from a person who is involved in making financial decisions. Thank you talking with us.

5. Have you bought a home or refinanced a mortgage in the past 5 years?

• Yes, bought

• Yes, refinanced

• No→ Skip to Question 7

6. Have you experienced a delinquency (foreclosure) or loan modification in the past five years?

• Yes

• No

7. Do you plan to buy a home or refinance a mortgage in the next year?

• Yes

• No

8. Have you owned a home in the past?

• Yes

• No

9. What is your gender?

• Male

• Female

10. Are you married?

• Yes

• No

11. 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

12. 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

13. What is your current age?

• 18–30

• 31–45

• 46-60

• Older than 60

14. 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

15. What is your current household income?

• Less than $35k

• $35,001-70,000

• $70,001-125,000

• Over $125,000

16. The Consumer Financial Protection Bureau 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 1505–0233, and expires 11/30/2011.