Foreclosure Counseling Intake Foreclosure Prevention Intake Form Step 1 of 9 11% How did you hear about us? I. Personal Information Borrowerfirst person listed on the loanTitle Mr Mrs Ms Dr Name First Middle Initial Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneExt Cell PhoneEmail Social Security Number Birthdate MM slash DD slash YYYY Race White, non-Hispanic Hispanic American Indian / Alaskan Native Black, non-Hispanic Asian / Pacific Islander Other Gender Male Female Disabled Yes No Veteran Yes No Education None Primary H.S. Diploma/Equivalent Vocational College Employer Start Date MM slash DD slash YYYY Job Title End Date MM slash DD slash YYYY Business Type Monthly GrossMonthly NetOther incomePLEASE UPLOAD A SEPARATE DESCRIPTION AND SOURCE OF ANY OTHER INCOMEMax. file size: 50 MB.Household Type Single Adult Married without children Married with children Two or more unrelated adults Female Headed Single parent household Male Headed Single parent household Other Household SizeNumber of DependentsWhat Ages? II. Personal Information Co-Borrowersecond person listed on the loanTitle Mr Mrs Ms Dr Name First Middle Initial Last Home PhoneWork PhoneExt Social Security Number Birthdate MM slash DD slash YYYY Race White, non-Hispanic Hispanic American Indian / Alaskan Native Black, non-Hispanic Asian / Pacific Islander Other Gender Male Female Disabled Yes No Veteran Yes No Education None Primary H.S. Diploma/Equivalent Vocational College Employer Start Date MM slash DD slash YYYY Job Title End Date MM slash DD slash YYYY Business Type Monthly GrossMonthly NetOther incomePLEASE UPLOAD A SEPARATE DESCRIPTION AND SOURCE OF ANY OTHER INCOMEMax. file size: 50 MB. III. HOUSEHOLD FINANCIAL INFORMATIONANNUAL FAMILY / HOUSEHOLD GROSS INCOME(your total household income each year before taxes)ESTIMATED ANNUAL HOUSEHOLD EXPENSES(your total household expenses each year)TOTAL OUTSTANDING DEBT(including mortgages, credit cards, loans, etc.) IV. MORTGAGE LOAN INFORMATIONPROPERTY IS A: Primary Residence Secondary Residence Investment DO YOU WANT TO KEEP YOUR HOME? Yes No DATE THE HOME WAS PURCHASED AMOUNT PAID FOR HOMEWHO IS YOUR CURRENT LENDER? Loan Number WHAT IS YOUR CURRENT INTEREST RATE?WHAT IS YOUR LOAN BALANCE?MONTHLY PAYMENT AMOUNT:amount before delinquencyDOES THIS INCLUDE TAXES & INSURANCE? Yes No Unknown HAVE YOU EVER REFINANCED? Yes No DATE OF REFINANCE:month/year IS YOUR LOAN: (refer to your loan documents)FIXED? Yes No ARM? Yes No INTEREST ONLY? Yes No HYBRID ARM? Yes No OPTION ARM? Yes No VA or FHA INSURED? Yes No If ARM Loan, what is the INTEREST RESET DATE? MM slash DD slash YYYY IS THERE A SECOND MORTGAGE ON THE PROPERTY? Yes No IF SO, WHAT IS THE BALANCE?WHO IS YOUR SECOND MORTGAGE LENDER? LOAN NUMBER WHAT IS YOUR CURRENT INTEREST RATE?Loan Type Fixed Adjustable IF ADJUSTABLE, MATURITY DATE: MM slash DD slash YYYY V. DEFAULT / DELINQUENCY INFORMATIONFIRST MORTGAGE:DATE OF LAST PAYMENT TO LENDERmonth & year AMOUNT OF PAYMENTwithout delinquencyHOW MANY MONTHS ARE YOU DELINQUENT?as of todayLAST TIME YOU SPOKE TO LENDERmonth & year DELINQUENCY AMOUNT:what is the amount your lender is asking you to pay?FIRST MORTGAGE:DATE OF LAST PAYMENT TO LENDERmonth & year AMOUNT OF PAYMENTwithout delinquencyHOW MANY MONTHS ARE YOU DELINQUENT?as of todayLAST TIME YOU SPOKE TO LENDERmonth & year DELINQUENCY AMOUNT:what is the amount your lender is asking you to pay? ARE YOUR PROPERTY TAXES ALSO IN DEFAULT? Yes No HAVE YOU (OR WILL YOU) FILE FOR BANKRUPTCY? Yes No ARE YOU DISCUSSING YOUR SITUATION WITH AN ATTORNEY? Yes No DO YOU HAVE HOMEOWNERS INSURANCE? Yes No Previous Delinquencies? Yes No When? Previous Workouts? Yes No When? Have you received other assistance? Yes No When? Who? Talked to Mortgage Company? Yes No Outcome: Is Loan Modification in progress? Yes No Own Home as Primary Residence? Yes No Rental Property In Bankruptcy? Yes No Is this situation caused by a: National Health Crisis Natural Disaster WHAT CAUSED YOU TO FALL BEHIND ON YOUR MORTGAGE PAYMENTS?WHAT ARE YOUR PLANS TO BRING THIS LOAN CURRENT?ARE YOU BEHIND ON ANY OTHER FINANCIAL OBLIGATIONS?List all creditors and amounts owed. VI. CONSENTI (We) acknowledge that a copy of this form is as valid as the original. By signing below, I (we) hereby certify that the above information is true and correct to the best of my (our) knowledge and belief.BORROWER:DATE: MM slash DD slash YYYY CO-BORROWER:DATE: MM slash DD slash YYYY
