Borrower Authorization

“Making the American dream a reality for all.”
Borrower Authorization of Third Party
Mortgage Servicer name*
Customer Service/Loss Mitigation Phone Number*
Borrower(s) name(s)*
Street Addrees*
City*
State*
Zip Code*
Mortgage loan account number(s)*
Third Party Information(all applicable fields must be completed)
Name of Entity, Agency, Firm
Phone number
Name(s) of authorized person(s)
Mailing address
Office address
Website URL
Tax ID#
State license # (if required)
Issuing state
For non-profit agencies only
HUD Approved Counseling Agency?

YesNo
Approval valid until (date)

MonthDayYear
Date
HUD HCS #
For attorneys only **
Do you represent the above named Borrower for a workout arrangement with the named Servicer?

YesNo
Firm Name
Individual Attorney name(s)
All states where licensed
Attorney who represents Borrower must sign below
Third Party Acknowledgement
The undersigned, on behalf of the Third Party, represents that: (i) it is in compliance with Regulation O (Mortgage Assistance Relief Services), if applicable, and all other applicable laws and regulations; and (ii) the Third Party information provided above is true and correct. The undersigned acknowledges that a misrepresentation or omission of fact made in connection with a government program such as Making Home Affordable may result in civil/criminal prosecution.
Signature of Third Party:
Thomas Griffin - HUD Housing Couneslor
Chris Castellanos - HUD Housing Counselor
Date

MonthDayYear
Date
BORROWER INITIALS*
Third Party you are authorizing (from first page)*
I (Borrowers listed below) authorize the above named Third Party to discuss, assist with, or, if applicable, negotiate a workout arrangement on my mortgage(s) with the above named Mortgage Servicer (its affiliates, agents, employees, and successors). A workout arrangement could include a modification or other relief.
I authorize my Mortgage Servicer, and Third Party and Treasury (and its agents) to share with each other public and non-public information about my finances and my mortgage for the purpose of assisting me in obtaining a workout arrangement, including but not limited to: (i) my mortgage payment history, terms of my mortgage; and (ii) my social security number, credit score, income, debts and other information related to obtaining and servicing my mortgage.
I understand that my Mortgage Servicer may contact me directly except in limited situations, such as when I am represented by an attorney, and the Servicer and I must agree to any workout arrangement. I may still contact my Mortgage Servicer at any time.
I understand that this Third Party Authorization Form may not be accepted by my Mortgage Servicer and my Mortgage Servicer will notify me in writing if it is not accepted. Mortgage Loan Servicers have procedures designed to detect fraud or improper activity and must follow privacy laws to protect borrower information.
This Authorization expires one year from the date signed unless Borrower cancels it earlier by writing to the Servicer or by completing an Authorization of a different Third Party.
Do not sign this form until the form is fully completed. Keep a copy of this form.

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Signature of borrower *

Clear
Printed name*
Date*

MonthDayYear
Date
Social Security Number *
Phone #*
Email*
example@example.com
Signature of co-borrower

Clear
Printed name
Date

MonthDayYear
Date
Social Security Number
Phone #
Email
example@example.com
This form should be transmitted to the Mortgage Servicer as soon as possible and no later than 90 days after the date signed.
Should be Empty:

Borrower Authorization of Third Party

For non-profit agencies only

For attorneys only **

Third Party Acknowledgement