Foreclosure Assistance Intake Form
Please fill out this form to apply for loss mitigation assistance. All information provided will be kept confidential.
Borrower Information
Name
First Name
Last Name
Property Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different from property address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Best Time to Contact
Morning
Afternoon
Evening
Loan Information
Loan Number
Loan Servicer
Loan Type
FHA
VA
USDA
Conventional
Other
Original Loan Amount
Current Loan Balance
Hardship Information
Type of Hardship (check all that apply)
Reduction in Income
Job Loss
Medical Expenses
Divorce/Separation
Death of Borrower/Co-Borrower
Natural Disaster
Increased Expenses
Other
Description of Hardship
Income and Employment Information
Borrower Employment Status
Employed
Self-Employed
Unemployed
Retired
Monthly Total Income $
Monthly Total Expences $
Requested Assistance
Type of Assistance Requested (check all that apply)
Loan Modification
Repayment Plan
Forbearance Plan
Short Sale
Deed in Lieu of Foreclosure
Other
Required Documents (attach copies)
Browse Files
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Proof of Income (pay stubs, tax returns), Bank Statements, Hardship Letter, Recent Mortgage Statement, Property Tax Statement, Homeowner’s Insurance Policy
Cancel
of
Date
-
Month
-
Day
Year
Date
Signature
Submit
Submit
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