Exemplar Response Form

OMB No. XXXX-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, loan originator, or settlement agent?

• 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 non-white populations?

• Yes, what population? ____________________________________________

• No

Mortgage brokers, lenders, loan originators, and settlement agents, please skip to Question 9

4. Would you be involved in the decision in your household about choosing and closing on a mortgage loan to buy a house or refinance?

• Yes, I participate in the decision-making

• No

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 own a home now?

• Yes → Skip to Question 9

• No

8. If no to Question 7, have you owned a home in the past?

• Yes

• No

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, and expires date.

9. What is your gender?

• Male

• Female

10. What is your marital status?

• Now married

• Widowed

• Divorced

• Separated

• Never married

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:

• American Indian or Alaska Native

• Asian

• Black/African American

• Native Hawaiian or other Pacific Islander

• White

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 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.