IFPN Housing Counselor Request

Indiana Foreclosure Prevention Network Housing Counselor Request
Name - Primary Applicant

First NameLast Name
Name - Co-Borrower

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Phone Number
Please enter a valid phone number.
Email
example@example.com
Annual Household Income -
Lender Name -   Type a label
Loan Number -   Type a label
Mortgage Type -   Type a label
How many months are you behind on your mortgage? Select one
Do you have a sheriff sale?

YesNo
If Yes, what is the sale date?

MonthDayYear
Date
Are you in active bankruptcy?

YesNo
Have you received mortgage assistance in the past?

YesNo
If Yes, select the program(s).
Should be Empty:

Indiana Foreclosure Prevention Network Housing Counselor Request