Form
Name
First Name
Last Name
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Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
Date
Preferred Method of Communication – Single Choice
Please Select
Phone
Text
Email
Are you a military veteran
Please Select
yes
no
List names and relationships of all household members over age 18
How many dependents do you have?
Is anyone in the household disabled or requiring special care?
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Current employment status
Employed
Unemployed
Retired
Self-Employed
Other
Employer name, job title, and length of employment (Short Text)
If unemployed, date of last employment and reason for unemployment
List all sources of income, including amounts for each household member ( Source, Amount, Frequency)
Are any sources temporary or expected to change?
Please Select
yes
no
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Mortgage servicer/lender/bank
Mortgage servicer/lender phone number
Mortgage servicer/lender email address
Type of loan
Please Select
FHA
SBA
VA
Conventional
USDA
Outstanding mortgage balance (Currency)
Monthly payment amount (Currency)
Payment frequency
Please Select
Monthly
Bi-Weekly
Other
Are property taxes and insurance included in the payment?
Please Select
yes
no
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Date of last full mortgage payment
-
Month
-
Day
Year
Date
Number of payments missed
Amount of arrears (Currency)
Have you received any notices from the lender?
Please Select
yes
no
If you selected, yes, please provide the date of the notice
Upload any notices from your lender
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Describe the primary hardship leading to default
Is the hardship temporary or permanent?
Has your hardship been resolved?
Which of the following have you experienced? (Multiple Choice; select all that apply)
Job loss or significant reduction in income
Medical emergency/major health expenses
Divorce/separation
Death of a primary wage earner
Unexpected increase in living expenses
Reduced home value (underwater mortgage)
Increased mortgage payments
Natural disaster or property damage
Other
If you selected other above, please specify
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List all major debts (Table: Type, Balance, Monthly Payment)
Any outstanding judgments or liens?
Please Select
yes
no
unsure
Checking/savings account balances (Currency) combined
Do you have any Retirement/investment accounts?
Please Select
yes
no
Do you have other significant assets (vehicles, real estate, valuables) list all below
Any non-cash assistance received? (e.g., from family/friends, government programs)
Do you have any cryptocurrency?
Please Select
yes
no
Do you have cash value life Insurance?
Please Select
yes
no
Do you have access to a TSP (Thrift Savings Plan) account from the military? (Yes/No; If Yes, provide details)
Please Select
yes
no
What's your current credit score?
what is the status of this property?
Please Select
vacant
rented
owner-occupied
Estimated market value of the property (Currency)
Any recent appraisal?
Please Select
yes
no
if yes provide date of appraisal
-
Month
-
Day
Year
Date
Condition of the property?
Please Select
great
good
fair
needs repair
If needs repair please specify
Have you previously applied for mortgage assistance?
Please Select
yes
no
If yes, provide the date
-
Month
-
Day
Year
Date
If Yes, describe outcome)
Are you currently working with a HUD counselor, attorney, or other third party?
Please Select
yes
no
If Yes, provide name/contact information/address )
What is your primary goal?
Save your Home
Sell
Deed-in-lieu,
Short-Sale
Are you willing and able to make a partial payment or trial payment?
Please Select
yes
no
If yes, Indicate amount?
Do you have a co-borrower/guarantor willing to assist?
Please Select
yes
no
Can you provide recent pay stubs, tax returns, bank statements, and hardship documentation?
Please Select
yes
no
need to
Do you authorize us to discuss your account with your mortgage servicer and third-party counselors?
Please Select
yes
no
Please share any additional information or concerns not covered above.
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