Completing Study

Appendix B to Supporting Statement of
Bureau of Consumer Financial Protection
Quantitative Testing of Integrated Mortgage Loan Disclosure Forms
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-XXXX, and it expires on XXXXXXX.

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. Completing this form is voluntary; you can choose not to answer any question,
and you can stop at any time. As was mentioned on the phone, the Consumer Financial Protection Bureau
(CFPB) is conducting a study to improve mortgage loan disclosures. We anticipate this application form taking
about 5 minutes of your time.
Please check the appropriate boxes.
1. Are you a mortgage loan broker, lender, loan originator, or settlement agent?
 Yes, please indicate which? _____________________________________
 No
2. Are you a realtor, appraiser, or title insurer, or do you work in an office that deals with the real estate
transactions?
 Yes, please indicate which? _____________________________________
 No
3. 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
4. Have you ever bought a house and financed it with a mortgage loan?
 Yes, bought Skip to Q6
 Yes, refinanced  Skip to Q6
 No  Continue to Q 5
5. Do you intend to buy a house and finance it with a mortgage loan within the next
 5 years  Skip to Q9
 10 years Skip to Q9
 15 years or more  Skip to Q9
 Never

Appendix B to Supporting Statement of
Bureau of Consumer Financial Protection
Quantitative Testing of Integrated Mortgage Loan Disclosure Forms
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-XXXX, and it expires on XXXXXXX.

6. Have you bought a house and financed it or refinanced a mortgage in the past 5 years?
 Yes, bought
 Yes, refinanced
 No
7. Do you intend to buy a house and finance it with a mortgage loan again or refinance again within the
next
 5 years
 10 years
 15 or more years
 Never
8. Have you experienced a delinquency, default, or foreclosure in the past five years?
 Yes
 No
9. What is your marital status?
 Now married
 Widowed
 Divorced
 Separated
 Never married
10. What is your current household income?
 Less than $35k
 $35,001-70,000
 $70,001-125,000
 Over $125,000

Appendix B to Supporting Statement of
Bureau of Consumer Financial Protection
Quantitative Testing of Integrated Mortgage Loan Disclosure Forms
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-XXXX, and it expires on XXXXXXX.

11. The Consumer Financial Protection Bureau has posted mortgage disclosure forms and a proposed rule
about the forms on its website. Have you seen these forms, commented on them, or previously
participated in a study about mortgage disclosure forms conducted by Kleimann Communication
Group?
 Yes
 No
Thank you. You have finished the questionnaire.