Qualitative Testing of Integrated Mortgage Loan Disclosure Forms - Round 10

OMB No. 3170-0003

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, please indicate which? _____________________________________

• No

2. 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

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

• Yes, bought

• Yes, refinanced

• No

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

• Yes

• No

5. Do you own a home now? (you may answer yes if are currently paying a mortgage or if you have paid it off)

• Yes → Skip to Question 7

• No

6. If no to Question 5, have you owned a home in the past?

• Yes

• No

7. What is your gender?

• Male

• Female

8. What is your marital status?

• Now married

• Widowed

• Divorced

• Separated

• Never married

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 3170-0003, and expires 11/30/2013.

9. 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

10. 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

11. What is your current age?

• 18–30

• 31–45

• 46-60

• Older than 60

12. 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

13. What is your current household income?

• Less than $35k

• $35,001-70,000

• $70,001-125,000

• Over $125,000

14. 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 3170-0003, and expires 11/30/2013.