Instructions for completing the IRS Form 4506-T

Instructions for completing the IRS Form 4506-T
We require a signed and dated copy of IRS Form 4506-T (Request for Transcript of Tax Return) for each
borrower. Borrowers who filed their tax returns jointly may send in one IRS Form 4506-T signed and
dated by both of the joint filers.
Below are instructions for completing this form:
Line 1a:
The borrower’s name must be printed clearly, exactly as it appears on the last tax return.
Line 1b:
The borrower’s social security number should be printed clearly with all nine digits
displayed. (Format: 123-45-6789.)
Line 2a:
If a joint return was filed, print spouse’s name clearly, exactly as it appears on the last tax
return.
Line 2b:
If a joint return was filed, the spouse’s Social Security number should be printed clearly
with all nine digits displayed. (Format: 123-45-6789.)
Line 3:
This is the current borrower’s address, including street address, city, state and Zip code.
If applicable, include apartment, room, or suite number.
Line 4:
If the address on the last tax return is different from the current address, insert the
address used on the last tax return here.
Line 5:
This has been pre-filled. No action is required.
Line 6:
Borrower must enter their tax form number.
Line 6a:
This has been pre-filled. No action is required.
Lines 6 b & c: These sections are not applicable and require no action.
Lines 7 & 8:
These sections are not applicable and require no action.
Line 9:
Enter the year of your most recent filed tax returns.
Signatory
Attests
Please check this box to confirm that you have the authority to sign the form 4506 – T.
This is an IRS requirement.
Signature:
The primary taxpayer should sign on the signature line. If the primary taxpayer is not
signing, a spouse should sign in the spouse’s signature line. It is only necessary for one of
the filers of a joint return to sign this form. If signed by a corporate officer, 1 percent or
more shareholder, partner, managing member, guardian, tax matters partner, executor,
receiver, administrator, trustee, or party other than the taxpayer will need to sign the
form.
Date:
A date is required with each signature.
Instructions for Completing IRS Form 4506-T
Page 1 of 1
Form
4506-T
(Rev. September 2015)
Department of the Treasury
Internal Revenue Service
Request for Transcript of Tax Return
Do not sign this form unless all applicable lines have been completed.
▶ Request may be rejected if the form is incomplete or illegible.
▶ For more information about Form 4506-T, visit www.irs.gov/form4506t.
▶
OMB No. 1545-1872
Tip. Use Form 4506-T to order a transcript or other return information free of charge. See the product list below. You can quickly request transcripts by using
our automated self-help service tools. Please visit us at IRS.gov and click on “Get a Tax Transcript...” under “Tools” or call 1-800-908-9946. If you need a copy
of your return, use Form 4506, Request for Copy of Tax Return. There is a fee to get a copy of your return.
1a Name shown on tax return. If a joint return, enter the name
shown first.
1b First social security number on tax return, individual taxpayer identification
number, or employer identification number (see instructions)
2a If a joint return, enter spouse’s name shown on tax return.
2b Second social security number or individual taxpayer
identification number if joint tax return
3 Current name, address (including apt., room, or suite no.), city, state, and ZIP code (see instructions)
4 Previous address shown on the last return filed if different from line 3 (see instructions)
5 If the transcript or tax information is to be mailed to a third party (such as a mortgage company), enter the third party’s name, address,
and telephone number.
Equifax, 11432 Lackland Rd. St. Louis, MO 63146
Caution: If the tax transcript is being mailed to a third party, ensure that you have filled in lines 6 through 9 before signing. Sign and date the form once
you have filled in these lines. Completing these steps helps to protect your privacy. Once the IRS discloses your tax transcript to the third party listed
on line 5, the IRS has no control over what the third party does with the information. If you would like to limit the third party’s authority to disclose your
transcript information, you can specify this limitation in your written agreement with the third party.
Transcript requested. Enter the tax form number here (1040, 1065, 1120, etc.) and check the appropriate box below. Enter only one tax form
number per request. ▶
6
a
Return Transcript, which includes most of the line items of a tax return as filed with the IRS. A tax return transcript does not reflect
changes made to the account after the return is processed. Transcripts are only available for the following returns: Form 1040 series,
Form 1065, Form 1120, Form 1120-A, Form 1120-H, Form 1120-L, and Form 1120S. Return transcripts are available for the current year
and returns processed during the prior 3 processing years. Most requests will be processed within 10 business days . . . . . .
b
Account Transcript, which contains information on the financial status of the account, such as payments made on the account, penalty
assessments, and adjustments made by you or the IRS after the return was filed. Return information is limited to items such as tax liability
and estimated tax payments. Account transcripts are available for most returns. Most requests will be processed within 10 business days .
c
Record of Account, which provides the most detailed information as it is a combination of the Return Transcript and the Account
Transcript. Available for current year and 3 prior tax years. Most requests will be processed within 10 business days
. . . . . .
✔
7
Verification of Nonfiling, which is proof from the IRS that you did not file a return for the year. Current year requests are only available
after June 15th. There are no availability restrictions on prior year requests. Most requests will be processed within 10 business days . .
8
Form W-2, Form 1099 series, Form 1098 series, or Form 5498 series transcript. The IRS can provide a transcript that includes data from
these information returns. State or local information is not included with the Form W-2 information. The IRS may be able to provide this
transcript information for up to 10 years. Information for the current year is generally not available until the year after it is filed with the IRS. For
example, W-2 information for 2011, filed in 2012, will likely not be available from the IRS until 2013. If you need W-2 information for retirement
purposes, you should contact the Social Security Administration at 1-800-772-1213. Most requests will be processed within 10 business days .
Caution: If you need a copy of Form W-2 or Form 1099, you should first contact the payer. To get a copy of the Form W-2 or Form 1099 filed
with your return, you must use Form 4506 and request a copy of your return, which includes all attachments.
9
Year or period requested. Enter the ending date of the year or period, using the mm/dd/yyyy format. If you are requesting more than four
years or periods, you must attach another Form 4506-T. For requests relating to quarterly tax returns, such as Form 941, you must enter
each quarter or tax period separately.
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Caution: Do not sign this form unless all applicable lines have been completed.
Signature of taxpayer(s). I declare that I am either the taxpayer whose name is shown on line 1a or 2a, or a person authorized to obtain the tax
information requested. If the request applies to a joint return, at least one spouse must sign. If signed by a corporate officer, 1 percent or more
shareholder, partner, managing member, guardian, tax matters partner, executor, receiver, administrator, trustee, or party other than the taxpayer, I
certify that I have the authority to execute Form 4506-T on behalf of the taxpayer. Note: For transcripts being sent to a third party, this form must be
received within 120 days of the signature date.
Signatory attests that he/she has read the attestation clause and upon so reading declares that he/she
has the authority to sign the Form 4506-T. See instructions.
▲ ▲ ▲
Sign
Here
Signature (see instructions)
Phone number of taxpayer on line
1a or 2a
Date
Title (if line 1a above is a corporation, partnership, estate, or trust)
Spouse’s signature
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
Date
Cat. No. 37667N
Form 4506-T (Rev. 9-2015)
Form 4506-T (Rev. 9-2015)
Page
Section references are to the Internal Revenue Code
unless otherwise noted.
Future Developments
For the latest information about Form 4506-T and its
instructions, go to www.irs.gov/form4506t.
Information about any recent developments affecting
Form 4506-T (such as legislation enacted after we
released it) will be posted on that page.
General Instructions
Caution: Do not sign this form unless all applicable
lines have been completed.
Purpose of form. Use Form 4506-T to request tax
return information. You can also designate (on line 5)
a third party to receive the information. Taxpayers
using a tax year beginning in one calendar year and
ending in the following year (fiscal tax year) must file
Form 4506-T to request a return transcript.
Note: If you are unsure of which type of transcript
you need, request the Record of Account, as it
provides the most detailed information.
Tip. Use Form 4506, Request for Copy of
Tax Return, to request copies of tax returns.
Automated transcript request. You can quickly
request transcripts by using our automated
self-help service tools. Please visit us at IRS.gov and
click on “Get a Tax Transcript...” under “Tools” or
call 1-800-908-9946.
Where to file. Mail or fax Form 4506-T to
the address below for the state you lived in,
or the state your business was in, when that return
was filed. There are two address charts: one for
individual transcripts (Form 1040 series and Form
W-2) and one for all other transcripts.
If you are requesting more than one transcript or
other product and the chart below shows two
different addresses, send your request to the
address based on the address of your most recent
return.
Chart for individual transcripts
(Form 1040 series and Form W-2
and Form 1099)
If you filed an
individual return
and lived in:
Alabama, Kentucky,
Louisiana, Mississippi,
Tennessee, Texas, a
foreign country, American
Samoa, Puerto Rico,
Guam, the
Commonwealth of the
Northern Mariana Islands,
the U.S. Virgin Islands, or
A.P.O. or F.P.O. address
Alaska, Arizona, Arkansas,
California, Colorado,
Hawaii, Idaho, Illinois,
Indiana, Iowa, Kansas,
Michigan, Minnesota,
Montana, Nebraska,
Nevada, New Mexico,
North Dakota, Oklahoma,
Oregon, South Dakota,
Utah, Washington,
Wisconsin, Wyoming
Connecticut, Delaware,
District of Columbia,
Florida, Georgia, Maine,
Maryland, Massachusetts,
Missouri, New Hampshire,
New Jersey, New York,
North Carolina, Ohio,
Pennsylvania, Rhode
Island, South Carolina,
Vermont, Virginia, West
Virginia
Mail or fax to:
Internal Revenue Service
RAIVS Team
Stop 6716 AUSC
Austin, TX 73301
512-460-2272
Internal Revenue Service
RAIVS Team
Stop 37106
Fresno, CA 93888
559-456-7227
Internal Revenue Service
RAIVS Team
Stop 6705 P-6
Kansas City, MO 64999
816-292-6102
Chart for all other transcripts
If you lived in or your business
was in: Alabama, Alaska,
Arizona, Arkansas,
California, Colorado,
Florida, Hawaii, Idaho,
Iowa, Kansas,
Louisiana, Minnesota,
Mississippi,
Missouri, Montana,
Nebraska, Nevada,
New Mexico,
North Dakota,
Oklahoma, Oregon,
South Dakota, Texas,
Utah, Washington,
Wyoming, a foreign
country, American
Samoa, Puerto Rico,
Guam, the
Commonwealth of the
Northern Mariana
Islands, the U.S. Virgin
Islands, or A.P.O. or
F.P.O. address
Connecticut,
Delaware, District of
Columbia, Georgia,
Illinois, Indiana,
Kentucky, Maine,
Maryland,
Massachusetts,
Michigan, New
Hampshire, New
Jersey, New York,
North Carolina,
Ohio, Pennsylvania,
Rhode Island, South
Carolina, Tennessee,
Vermont, Virginia,
West Virginia,
Wisconsin
Mail or fax to: Internal Revenue Service
RAIVS Team
P.O. Box 9941
Mail Stop 6734
Ogden, UT 84409
801-620-6922
2
Corporations. Generally, Form 4506-T can be
signed by: (1) an officer having legal authority to bind
the corporation, (2) any person designated by the
board of directors or other governing body, or (3)
any officer or employee on written request by any
principal officer and attested to by the secretary or
other officer. A bona fide shareholder of record
owning 1 percent or more of the outstanding stock
of the corporation may submit a Form 4506-T but
must provide documentation to support the
requester's right to receive the information.
Partnerships. Generally, Form 4506-T can be
signed by any person who was a member of the
partnership during any part of the tax period
requested on line 9.
All others. See section 6103(e) if the taxpayer has
died, is insolvent, is a dissolved corporation, or if a
trustee, guardian, executor, receiver, or
administrator is acting for the taxpayer.
Note: If you are Heir at law, Next of kin, or
Beneficiary you must be able to establish a material
interest in the estate or trust.
Documentation. For entities other than individuals,
you must attach the authorization document. For
example, this could be the letter from the principal
officer authorizing an employee of the corporation or
the letters testamentary authorizing an individual to
act for an estate.
Internal Revenue Service
RAIVS Team
P.O. Box 145500
Stop 2800 F
Cincinnati, OH 45250
859-669-3592
Line 1b. Enter your employer identification number
(EIN) if your request relates to a business return.
Otherwise, enter the first social security number
(SSN) or your individual taxpayer identification
number (ITIN) shown on the return. For example, if
you are requesting Form 1040 that includes
Schedule C (Form 1040), enter your SSN.
Line 3. Enter your current address. If you use a P.O.
box, include it on this line.
Line 4. Enter the address shown on the last return
filed if different from the address entered on line 3.
Signature by a representative. A representative
can sign Form 4506-T for a taxpayer only if the
taxpayer has specifically delegated this authority to
the representative on Form 2848, line 5. The
representative must attach Form 2848 showing the
delegation to Form 4506-T.
Privacy Act and Paperwork Reduction Act Notice.
We ask for the information on this form to establish
your right to gain access to the requested tax
information under the Internal Revenue Code. We
need this information to properly identify the tax
information and respond to your request. You are
not required to request any transcript; if you do
request a transcript, sections 6103 and 6109 and
their regulations require you to provide this
information, including your SSN or EIN. If you do not
provide this information, we may not be able to
process your request. Providing false or fraudulent
information may subject you to penalties.
Routine uses of this information include giving it to
the Department of Justice for civil and criminal
litigation, and cities, states, the District of Columbia,
and U.S. commonwealths and possessions for use
in administering their tax laws. We may also disclose
this information to other countries under a tax treaty,
to federal and state agencies to enforce federal
nontax criminal laws, or to federal law enforcement
and intelligence agencies to combat terrorism.
Line 6. Enter only one tax form number per
request.
You are not required to provide the information
requested on a form that is subject to the Paperwork
Reduction Act unless the form displays a valid OMB
control number. Books or records relating to a form
or its instructions must be retained as long as their
contents may become material in the administration
of any Internal Revenue law. Generally, tax returns
and return information are confidential, as required
by section 6103.
Signature and date. Form 4506-T must be signed
and dated by the taxpayer listed on line 1a or 2a. If
you completed line 5 requesting the information be
sent to a third party, the IRS must receive Form
4506-T within 120 days of the date signed by the
taxpayer or it will be rejected. Ensure that all
applicable lines are completed before signing.
The time needed to complete and file Form
4506-T will vary depending on individual
circumstances. The estimated average time is:
Learning about the law or the form, 10 min.;
Preparing the form, 12 min.; and Copying,
assembling, and sending the form to the IRS,
20 min.
You must check the box in the signature
area to acknowledge you have the
authority to sign and request the
information. The form will not be
CAUTION
processed and returned to you if the
box is unchecked.
If you have comments concerning the accuracy of
these time estimates or suggestions for making
Form 4506-T simpler, we would be happy to hear
from you. You can write to:
Note: If the addresses on lines 3 and 4 are different
and you have not changed your address with the
IRS, file Form 8822, Change of Address. For a
business address, file Form 8822-B, Change of
Address or Responsible Party — Business.
!
▲
Individuals. Transcripts of jointly filed tax returns
may be furnished to either spouse. Only one
signature is required. Sign Form 4506-T exactly as
your name appeared on the original return. If you
changed your name, also sign your current name.
Internal Revenue Service
Tax Forms and Publications Division
1111 Constitution Ave. NW, IR-6526
Washington, DC 20224
Do not send the form to this address. Instead, see
Where to file on this page.
UNIFORM BORROWER ASSISTANCE FORM
If you are experiencing a temporary or long-term hardship and need help, you must complete and submit this form along
with other required documentation to be considered for available solutions. On this page, you must disclose information
about (1) you and your intentions to either keep or transition out of your home; (2) the property’s status; (3) bankruptcy;
and (4) your credit counseling agency.
On Page 2, you must disclose information about all of your income, expenses and assets. Page 2 also lists the required
income documentation that you must submit in support of your request for assistance. Then on Page 3, you must
complete the Hardship Affidavit in which you disclose the nature of your hardship. The Hardship Affidavit informs you of
the required documentation that you must submit in support of your hardship claim.
NOTICE: In addition, when you sign and date this form, you will make important certifications, representations and
agreements, including certifying that all of the information in this Borrower Assistance Form is accurate and truthful
and any identified hardship has contributed to your submission of this request for mortgage relief.
REMINDER: The Borrower Response Package you need to return consists of: (1) this completed, signed and dated
Borrower Assistance Form; (2) completed and signed IRS Form 4506T-EZ (4506T for self-employed borrowers or
borrowers with rental income); (3) required income documentation; and (4) required hardship documentation.
Loan Number ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ (usually found on your monthly mortgage statement)
Servicer’s Nameͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
I want to:
Keep the Property
Vacate the Property
Sell the Property
The property is currently:
My Primary Residence
A Second Home
An Investment Property
The property is currently:
Owner Occupied
Renter Occupied
Vacant
BORROWER
Undecided
CO-BORROWER
BORROWER’S NAME
CO-BORROWER’S NAME
SOCIAL SECURITY NUMBER
DATE OF BIRTH
SOCIAL SECURITY NUMBER
DATE OF BIRTH
HOME PHONE NUMBER WITH AREA CODE
HOME PHONE NUMBER WITH AREA CODE
CELL OR WORK NUMBER WITH AREA CODE
CELL OR WORK NUMBER WITH AREA CODE
MAILING ADDRESS
PROPERTY ADDRESS (IF SAME AS MAILING ADDRESS, JUST WRITE SAME)
EMAIL ADDRESS
Is the property listed for sale?
Yes
No
If yes, what was the listing date? ___________
If property has been listed for sale, have you received an offer on the
Yes
No
property?
Date of offer:
___________ Amount of Offer: $ _______________
Agent’s Name: ____________________________________________
Agent’s Phone Number:
For Sale by Owner?
Yes
No
Do you have condominium or homeowner association (HOA) fees?
Yes
Total monthly amount: $
Have you filed for bankruptcy?
Have you contacted a credit counseling agency for help?
Yes
No
If yes, please complete the counselor contact information below:
Counselor’s Name: ___________________________________
Agency’s Name:
___________________________________
Counselor’s Phone Number: ____________________________
Counselor’s Email Address: ____________________________
No
Name and address that fees are paid to:
Yes
No
If yes:
Chapter 7
If yes, what is the filing Date: __________ Has your bankruptcy been discharged?
Chapter 11
Yes
No
Chapter 12
Bankruptcy case number: ______________
Is any Borrower an active duty service member?
Has any Borrower been deployed away from his/her primary residence or received a Permanent Change of Station order?
Is any Borrower the surviving spouse of a deceased service member who was on active duty at the time of death?
Fannie Mae/Freddie Mac Form 710
Page 1 of 4
Chapter 13
Yes
Yes
Yes
No
No
No
June 2014
UNIFORM BORROWER ASSISTANCE FORM
Monthly Household Income
Monthly Household Expenses and Debt Household Assets (associated with the
Payments
property and/or borrower(s)excluding
retirement funds)
Gross wages
$
First Mortgage Payment
$
Checking Account(s)
$
Overtime
$
Second Mortgage Payment
$
Checking Account(s)
$
Child Support / Alimony*
$
Homeowner’s Insurance
$
Savings / Money Market
$
Non-taxable social security/SSDI
$
Property Taxes
$
CDs
$
Taxable SS benefits or other monthly
$
Credit Cards / Installment Loan(s) (total $
Stocks / Bonds
$
income from annuities or retirement
minimum payment per month)
plans
Tips, commissions, bonus and self-
$
Alimony, child support payments
$
Other Cash on Hand
$
Rents Received
$
Car Lease Payments
$
Other Real Estate (estimated value)
$
Unemployment Income
$
HOA/Condo Fees/Property Maintenance $
Other
$
Food Stamps/Welfare
$
Mortgage Payments on other properties $
$
Other
$
Other
$
$
Total (Gross income)
$0
Total Household Expenses and Debt
$0
employed income
Total Assets
$0
Payments
Any other liens (mortgage liens, mechanics liens, tax liens, etc.)
Lien Holder’s Name
Balance and Interest Rate
Loan Number
Lien Holder’s Phone Number
Required Income Documentation
Do you earn a salary or hourly wage?
For each borrower who is a salaried employee or
paid by the hour, include paystub(s) reflecting the
most recent 30 days’ or four weeks' earnings and
documentation reflecting year-to-date earnings, if
not reported on the paystubs (e.g. signed letter or
printout from employer).
Are you self-employed?
For each borrower who receives self-employed income, include a complete, signed
individual federal income tax return and, as applicable, the business tax return; AND
either the most recent signed and dated quarterly or year-to-date profit/loss statement
that reflects activity for the most recent three months; OR copies of bank statements for
the business account for the last two months evidencing continuation of business
activity.
Do you have any additional sources of income? Provide for each borrower as applicable:
“Other Earned Income” such as bonuses, commissions, housing allowance, tips, or overtime:
Reliable third-party documentation describing the amount and nature of the income (e.g., paystub, employment contract or printouts
documenting tip income).
Social Security, disability or death benefits, pension, public assistance, or adoption assistance:
Documentation showing the amount and frequency of the benefits, such as letters, exhibits, disability policy or benefits statement from the
provider, and
Documentation showing the receipt of payment, such as copies of the two most recent bank statements showing deposit amounts.
Rental income:
Copy of the most recent filed federal tax return with all schedules, including Schedule E—Supplement Income and Loss. Rental income for
qualifying purposes will be 75% of the gross rent you reported reduced by the monthly debt service on the property, if applicable; or
If rental income is not reported on Schedule E – Supplemental Income and Loss, provide a copy of the current lease agreement with either
bank statements or cancelled rent checks demonstrating receipt of rent.
Investment income:
Copies of the two most recent investment statements or bank statements supporting receipt of this income.
Alimony, child support, or separation maintenance payments as qualifying income:*
Copy of divorce decree, separation agreement, or other written legal agreement filed with a court, or court decree that states the amount
of the alimony, child support, or separation maintenance payments and the period of time over which the payments will be received, and
Copies of your two most recent bank statements or other third-party documents showing receipt of payment.
*Notice: Alimony, child support, or separate maintenance income need not be revealed if you do not choose to have it considered for repaying
this loan.
Fannie Mae/Freddie Mac Form 710
Page 2 of 4
June 2014
UNIFORM BORROWER ASSISTANCE FORM
HARDSHIP AFFIDAVIT
I am requesting review of my current financial situation to determine whether I qualify for temporary or permanent mortgage loan relief
options.
Date Hardship Began is:
I believe that my situation is:
Short-term (under 6 months)
Medium-term (6 – 12 months)
Long-term or Permanent Hardship (greater than 12 months)
I am having difficulty making my monthly payment because of reason set forth below:
(Please check the primary reason and submit required documentation demonstrating your primary hardship)
If Your Hardship is:
Unemployment
Reduction in Income: a hardship that
has caused a decrease in your income
due to circumstances outside your
control (e.g., elimination of overtime,
reduction in regular working hours, a
reduction in base pay)
Increase in Housing Expenses: a
hardship that has caused an increase in
your housing expenses due to
circumstances outside your control
Divorce or legal separation; Separation
of Borrowers unrelated by marriage,
civil union or similar domestic
partnership under applicable law
Death of a borrower or death of either
the primary or secondary wage earner
in the household
Long-term or permanent disability;
Serious illness of a borrower/coborrower or dependent family member
Then the Required Hardship Documentation is:
No hardship documentation required
No hardship documentation required
No hardship documentation required
Divorce decree signed by the court; OR
Separation agreement signed by the court; OR
Current credit report evidencing divorce, separation, or non-occupying
borrower has a different address; OR
Recorded quitclaim deed evidencing that the non-occupying Borrower or coBorrower has relinquished all rights to the property
Death certificate; OR
Obituary or newspaper article reporting the death
Proof of monthly insurance benefits or government assistance (if applicable); OR
Written statement or other documentation verifying disability or illness; OR
Doctor’s certificate of illness or disability; OR
Medical bills
None of the above shall require providing detailed medical information.
Disaster (natural or man-made)
Insurance claim; OR
Federal Emergency Management Agency grant or Small Business Administration
adversely impacting the property or
loan; OR
Borrower’s place of employment
Borrower or Employer property located in a federally declared disaster area
Distant employment transfer / Relocation For active duty service members: Notice of Permanent Change of Station (PCS) or
actual PCS orders.
For employment transfers/new employment:
Copy of signed offer letter or notice from employer showing transfer to a new
employment location; OR
Paystub from new employer
In addition to the above, documentation that reflects the amount of any relocation
assistance provided, if applicable (not required for those with PCS orders).
Business Failure
Other: a hardship that is not covered
above
Fannie Mae/Freddie Mac Form 710
Tax return from the previous year (including all schedules) AND
Proof of business failure supported by one of the following:
Bankruptcy filing for the business; OR
Two months recent bank statements for the business account evidencing
cessation of business activity; OR
Most recent signed and dated quarterly or year-to-date profit and loss
statement
Written explanation describing the details of the hardship and relevant
documentation
Page 3 of 4
June 2014
Borrower/Co-Borrower Acknowledgement and Agreement
I certify, acknowledge, and agree to the following:
1. All of the information in this Borrower Assistance Form is truthful and the hardship that I have identified
contributed to my need for mortgage relief.
2. The accuracy of my statements may be reviewed by the Servicer, owner or guarantor of my mortgage, their
agent(s), or an authorized third party*, and I may be required to provide additional supporting documentation.
I will provide all requested documents and will respond timely to all Servicer, or authorized third party*,
communications.
3. Knowingly submitting false information may violate Federal and other applicable law.
4. If I have intentionally defaulted on my existing mortgage, engaged in fraud or misrepresented any fact(s) in
connection with this request for mortgage relief or if I do not provide all required documentation, the Servicer
may cancel any mortgage relief granted and may pursue foreclosure on my home and/or pursue any available
legal remedies.
5. The Servicer is not obligated to offer me assistance based solely on the representations in this document or
other documentation submitted in connection with my request.
6. I may be eligible for a trial period plan, repayment plan, or forbearance plan. If I am eligible for one of these
plans, I agree that:
a. All the terms of this Acknowledgment and Agreement are incorporated into such plan by reference as
if set forth in such plan in full.
b. My first timely payment under the plan will serve as acceptance of the terms set forth in the notice of
the plan sent by the Servicer.
c. The Servicer’s acceptance of any payments under the plan will not be a waiver of any acceleration of
my loan or foreclosure action that has occurred and will not cure my default unless such payments are
sufficient to completely cure my entire default under my loan.
d. Payments due under a trial period plan for a modification will contain escrow amounts. If I was not
previously required to pay escrow amounts, and my trial period plan contains escrow amounts, I agree
to the establishment of an escrow account and agree that any prior waiver is revoked. Payments due
under a repayment plan or forbearance plan may or may not contain escrow amounts. If I was not
previously required to pay escrow amounts and my repayment plan or forbearance plan contains
escrow amounts, I agree to the establishment of an escrow account and agree that any prior escrow
waiver is revoked.
7. A condemnation notice has not been issued for the property.
8. The Servicer or authorized third party* will obtain a current credit report on all borrowers obligated on the
Note.
9. The Servicer or authorized third party* will collect and record personal information that I submit in this
Borrower Response Package and during the evaluation process. This personal information may include, but is
not limited to: (a) my name, address, telephone number, (b) my social security number, (c) my credit score, (d)
my income, and (e) my payment history and information about my account balances and activity. I understand
and consent to the Servicer or authorized third party*, as well as any investor or guarantor (such as Fannie
Mae or Freddie Mac), disclosing my personal information and the terms of any relief or foreclosure alternative
that I receive to the following:
a. Any investor, insurer, guarantor, or servicer that owns, insures, guarantees, or services my first lien or
subordinate lien (if applicable) mortgage loan(s) or any companies that perform support services to
them; and
b. The U.S. Department of Treasury, Fannie Mae and Freddie Mac, in conjunction with their
responsibilities under the Making Home Affordable program, or any companies that perform support
services to them.
10. I consent to being contacted concerning this request for mortgage assistance at any telephone number,
including mobile telephone number, or email address I have provided to the Lender/Servicer/ or authorized
third party*. By checking this box, I also consent to being contacted by text messaging.
_________________________________ __________ ___________________________ __________
Borrower Signature
Date
Co-Borrower Signature
Date
*An authorized third party may include, but is not limited to, a counseling agency, Housing Finance Agency (HFA) or
other similar entity that is assisting me in obtaining a foreclosure prevention alternative.
Fannie Mae/Freddie Mac Form 710
Page 4 of 4
June 2014