Financial Intake Form

Please fill out and sign the secure Financial Intake Form below.
If you prefer, you may download the PDF form and fax it to (443) 371-9893
If you have questions, please call 800-326-5799 to speak with an Aspen representative.

Borrower Name

First NameLast Name

Social Security Number

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number (Preferred)

Area CodePhone Number

Email

example@example.com

Employer Name

Annual Gross Income

Other Income

Net Monthly Income

Co-Borrower Name

First NameLast Name

Co-Borrower Social Security Number

Co-Borrower Date of Birth

Date

Co-Borrower Address

Street Address

Street Address Line 2

CityState

Zip Code

Co-Borrower Phone Number (Preferred)

Area CodePhone Number

Co-Borrower Email

example@example.com

Co-Borrower Employer Name

Co-Borrower Annual Gross Income

Co-Borrower Other Income

Co-borrower Net Monthly Income

Do you want to keep your home?

Are you currently living in the home?

Is your home currently in foreclosure?

Have you ever had a loan modification or forbearance?

When?

Date

Have you ever filed bankruptcy?

When?

Date

Number of people in the household?

Current value of the home?

Resources available to pay towards defaulted mortgage?

Income Sources

Rows	Borrower	Co-Borrower
Wages (before taxes)
Unemployment Income
SSI/SSDI
Retirement/Pension
Rents Received
Child support/alimony*
Other

Expenses

Rows	Monthly	Annual	Total Owed
1st Mortgage Payment
If not escrowed, property taxes
If not escrowed, homeowner's insurance
If not escrowed, HOA dues
Auto Expenses (gas, maintenance, etc.)
Auto Insurance
Credit Cards
Child Care, Alimony, Child Support
Food
Utilities
Communications (cell, cable, internet)
Miscellaneous Spending
Auto Loans
Installment Loans
Medical Expenses
Student Loans

1. I/we represent that I am/we are currently occupying the property securing the loan as my/our
primary residence. If I am /we are currently occupying the property, I/we also represent that
I/we intend to continue occupying the property as my/our primary residence.

2. Under penalty of perjury, I/we certify that all documents and information that I/we provide to
the Housing Counselor and the Lender/Servicer, including the documents and information
regarding my eligibility for any modification or eligibility for any Foreclosure Mediation
Program, are true and correct and accurately reflect my financial status. My Lender/Servicer
may discuss, obtain and share information about my mortgage and financial situation with
third parties regarding a possible alternative to foreclosure.

3. I/we understand and acknowledge the Lender/Servicer may investigate the accuracy of
my/our statements, may require me/us to provide supporting documentation, and that
knowingly submitting false information may violate state and Federal law.

4. I/we understand that if I/we have intentionally engaged in fraud or misrepresented any fact(s),
or if I/we do not provide all of the required documentation, the Lender/Servicer may refuse to
consider any modification or alternative to foreclosure.

5. I/we certify that I am /we are willing to provide all requested documents and to respond to
Housing Counselor/Mediator/Lender/Servicer communications in a timely manner. I/we
understand that time is of the essence and intentional delays on my/our part could result in
making me/us ineligible for the Foreclosure Mediation Program.

6. I/we understand that negotiations for a possible foreclosure alternative will not constitute a
waiver or defense to my Lender's/Servicer's right to commence or continue any foreclosure or
other collection action.

7. I/we understand that an alternative to foreclosure will only be provided if an agreement has
been approved in writing by my Lender/Servicer.

Supporting Documentation

Browse Files

Signature

Co-borrower Signature