Intake Form

Intake Form

Please complete for your consultation
Name*

First NameLast Name

Phone Number*
Please enter a valid phone number.

Email*
example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you a Senior, Veteran, or Disabled?

YesNo

Are you a homeowner?

YesNo

Please select the option that fits your case best*

Have your property taxes increased recently?

YesNo
Number of properties you own
Is the property mortgage free?

YesNo
What is the mortgage balance for all properties?
What is the value of your property or properties?
What county is the property located in?

Any prior appeals?

YesNo
Any prior exemptions filed?

YesNo

What is your monthly mortgage payment?
Are you behind on payments?

YesNo

Have you received a foreclosure notice?

YesNo

Do you have a sale date or court date?

YesNo
Please enter your sale date or court date.

MonthDayYear
Date

Have you had prior modifications or workout assistance?

YesNo
How many prior modifications or workout assistances have you utilized?

Please select the grade of charge:

TrafficMisdemeanorFelonyOther

Do you have an upcoming court hearing?

YesNo
What is your court date?

MonthDayYear
Date

Employer Name
Monthly Income
Date of Last Pay Period

MonthDayYear
Date
Pay Frequency
Total Balance in Checking/Savings/401k

Tell us about your situation and why you are needing assistance.
In order to properly assist you, please provide the following (if applicable): 1).Mortgage Statement 2). Copy of any default notices, lender notices, or foreclosure notices. 3). Proof of Income (check stub, ss letter, or bank statement) Documents may be loaded by clicking on the (file upload) field below.

Cancelof
Should be Empty: