Foreclosure Intervention

APPLICATION FOR MORTGAGE ASSISTANCE

Default/Foreclosure Intervention
How did you hear about our agency?*

Indiana Foreclosure Prevention NetworkWorkOne OfficeI was a Previous ClientFriend/RelativeMy Mortgage LenderHUD WebsiteOther
First Name (Person First on Mortgage Loan)*
Last Name*
Place of Birth *
Date of Birth*

MonthDayYear
Date
Social Security Number*
Address *
City*
State*
ZIP Code*
How long at address?
Years*
Months
Home Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Best Time to Call

:HourMinutesAM/PM Option
Email Address*
example@example.com
Preferred Method of Contact:*

Home PhoneWork PhoneCell PhoneEmail
Marital Status*

SingleMarriedDivorcedSeparatedWidowed
Citizenship*

U.S. CitizenNon-Resident AlienPermanent Resident Alien
Country of Origin
Language*

Household is Limited English ProficientHousehold is Not Limited English ProficientChoose not to respond
Highest Education Level completed*

GEDHigh School DiplomaVocational CertificateSome CollegeAssociates DegreeBachelor DegreeMaster's DegreeDoctoral Degree
Co-Borrower’s Full Name (If on Mortgage Loan)
Place of Birth
Date of Birth

MonthDayYear
Date
Social Security Number
Address
City
State
ZIP Code
How long at address?
Years
Months
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Best Time to Call

:HourMinutesAM/PM Option
Email Address
example@example.com
Preferred Method of Contact:

Home PhoneWork PhoneCell PhoneEmail
Marital Status

SingleMarriedDivorcedSeparatedWidowed
Citizenship

U.S. CitizenNon-Resident AlienPermanent Resident Alien
Country of Origin
Language

Household is Limited English ProficientHousehold is Not Limited English ProficientChoose not to respond
Highest Education Level completed

GEDHigh School DiplomaVocational CertificateSome CollegeAssociates DegreeBachelor DegreeMaster's DegreeDoctoral Degree
List all the adults and children who currently live in your household*
Total Number of Household Members(including you)*
Are any Dependents Disabled?

YesNo
Who is your mortgage lender?*
What is your monthly mortgage payment? ($)*
Are you currently in a forbearance, modification, or repayment plan? If so, please describe including dates.
EMPLOYMENT/INCOME INFORMATION
Are you currently unemployed?*

YesNo
If you are receiving unemployment, how much per month($)?
What was the last date of work?

MonthDayYear
Date
Borrower’s Employer Name
Position
Address
City
State
Zip
Employer’s Phone

Area CodePhone Number
Starting Date

MonthDayYear
Date
Years In Profession
Status

Full-TimePart-TimeTemporaryLaid OffOther
Monthly Gross Pay (Before Deductions) $
Monthly Net Pay (After Deductions) $
Have you been unemployed anytime since January 2020 ?

YesNo
If you are retired, what was the last date of employment?

MonthDayYear
Date
Retirement Income($)
Is your financial hardship due to COVID? This includes layoff for shutdowns, COVID illness, etc.

YesNo
Did you utilize a forbearance from your mortgage lender during COVID?

YesNo
Are you in a modification or a repayment plan with your lender?

YesNo
LIST ALL OTHER SOURCES OF MONTHLY HOUSEHOLD INCOME (Income of every person who is or will be living in the household)

(Example: Additional jobs, Child Support, Social Security, SSI, Pensions, Unemployment, etc.)
All Other Income
TOTAL ALL OTHER INCOME (from previous list)*
PUBLIC ASSISTANCES
Are you receiving Food Stamps?

YesNo
If yes, how much per month ($)?
Are you receiving TANF?

YesNo
If yes, how much per month ($)?
LIST TOTAL ASSETS ON HAND AND THEIR CURRENT MARKET VALUE
Retirement Accounts (Roth IRA’s, IRA’s, 401k’s, etc.)
Bank Account (Include CD’s)
Personal Possessions (Coin Collections, Antiques, Vehicles, Other Real Estate Property, etc)
Whole Life Insurance (Cash Value Only)
Trust Funds/Other
TOTAL ALL ASSETS (FROM PREVIOUS LIST)*
QUESTIONNAIRE
(Please check the appropriate boxes yes or no and Borrower or Co-Borrower)
1. Have you or your Co-Borrower filed bankruptcy in the last 10 years?
Borrower*

YesNo
If so, when was it filed?

MonthDayYear
Date
When did it discharge?

MonthDayYear
Date
Co-Borrower

YesNo
If so, when was it filed?

MonthDayYear
Date
When did it discharge?

MonthDayYear
Date
2. Are there any judgements or collections against you?
Borrower*

YesNo
Co-Borrower

YesNo
Are they paid?
Borrower

YesNo
Co-Borrower

YesNo
3. Did you file Head of Household on your federal tax return?
Borrower*

YesNo
Co-Borrower

YesNo
4. Are you a United States Veteran?
Borrower*

YesNo
Co-Borrower

YesNo
5. Are you disabled?
Borrower*

YesNo
Co-Borrower

YesNo
6. Are you a migrant farm worker?
Borrower*

YesNo
Co-Borrower

YesNo
7. Did anyone contact you offering assistance to modify your mortgage, either directly by phone, or by other means (mail, flyer, etc.?)
Borrower*

YesNo
Co-Borrower

YesNo
8. Were you guaranteed a loan modification or asked to do any of the following: pay a fee, sign a contract, redirect mortgages, sign over title to your property, or stop making loan payments?
Borrower*

YesNo
Co-Borrower

YesNo
Rural Area Status:*

Household lives in a rural areaHousehold does not live in a rural areaChoose not to respond
How far behind on your mortgage payments?
First Mortgage*

Not Late30 - 60 days late61 - 90 days late91 - 120 days late121+ days late
Second Mortgage

Not Late30 - 60 days late61 - 90 days late91 - 120 days late121+ days late
Please describe your hardship preventing you from paying your mortgage, including dates it started below.*
I/We, as attested by my/our signature(s) below, certify that the information I/we provided in this application is true and accurate to the best of my/our knowledge.
Borrower's Signature*

Clear
Date*

MonthDayYear
Date
Co-Borrower Signature

Clear
Date

MonthDayYear
Date
INFORMATION FOR GOVERNMENT MONITORING PURPOSES

The following is requested by the federal government in order to monitor compliance with federal statutes that prohibit discrimination in housing. You are not required to furnish this information but are encouraged to do so. The law provides that an agency, lender, or server may not discriminate either on the basis of this information, or on whether you choose to furnish it. If you furnish the information, please provide both ethnicity and race. For race, you may check more than one designation. If you do not furnish ethnicity, race, or sex, HOPE of Evansville, Inc. is required to note the information on the basis of visual observation or surname, if you have made this request for foreclosure assistance in person. If you do not wish to furnish this information, please check the box below.
Borrower

I do not wish to furnish this information
Co-Borrower

I do not wish to furnish this information
Borrower's Ethnicity

Hispanic or LatinoNot Hispanic or Latino
Co-Borrower's Ethnicity

Hispanic or LatinoNot Hispanic or Latino
Borrower's Race

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite
Co-Borrower's Race

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite
Borrower's Sex

FemaleMaleChoose not to respond
Co-Borrower's Sex

FemaleMaleChoose not to respond
Should be Empty:

APPLICATION FOR MORTGAGE ASSISTANCE