Foreclosure Prevention Intake Form I. CLIENT INFORMATION Date

Foreclosure Prevention Intake Form
I. CLIENT INFORMATION
Date:
Name(s)
Address
Home Phone
Work Phone
Best Times to Reach
Marital Status
Spouse (if any)
Children (names and ages)
Others in Household:
II. INFORMATION ABOUT HOME BEING FORECLOSED
Address of Property (if different from above)
Names of all Co-owners w/ Address (if different)
Year Purchased
Original Purchase Price
Estimate of Current Value
Number of Room
Owner Occupant?
Yes
No
At purchase?
Yes
No
Now?
Yes
No
Yes
No
Multi-Family Home?
Name of tenants
Rent received
Condition:
Exc
Good
Fair
Poor
Major repairs needed
Describe:
Number of Mortgages
Other Liens
Notes:
III. MORTGAGE
Please note: some information about the mortgage may be
obtained after a review of the client’s records.
Type of Mortgage
Purchase Money
Refinance
Home Equity Loan
Debt Consolidation
Other
Year of Mortgage
Original Amount
Has client brought original loan papers? Yes
No
Current Lender or Servicer
Address of Current Lender or Servicer
Phone:
Fax:
Contact Person
Loan Account Number
Investor/Insurer
FHA Insured
VA
RHS
Fannie Mae
Freddie Mac
PMI
Other
Term of mortgage (in months)
Interest Rate
Principal and Interest Payment (monthly)
Tax and Insurance Payment (monthly)
Total Monthly Payment
Months Behind
Total Arrears Including Costs
Current Principal Balance
Payoff Amount
Is Client in Default?
Yes
Status/Amount of Monthly Payment
No
Reason for Default
Client’s Statement of Objectives and Plan
Other Mortgages and Liens
Yes ______
No ______
Describe
Notes:
IMPORTANT NOTE: If there are other mortgages, obtain
information for each using the questions on the form above.
IV. HOUSEHOLD FINANCIAL INFORMATION
INCOME BUDGET FOR HOUSEHOLD
SOURCE OF INCOME
Employment
Overtime
Child
Support/Alimony
Pension
Interest
Public Benefits
Dividends
Trust Payments
Royalties
Rents Received
Other (List)
TOTAL (MONTHLY)
LAST MO.
ACTUAL
$
THIS MO.
EXPECTED
$
THIS MO.
ACTUAL
$
ADJUSTED
MONTHLY
$
$
$
$
$
NOTES/ANTICIPATED CHANGES:
EXPENSE BUDGET FOR HOUSEHOLD
TYPE OF EXPENSE
Payroll Deductions
Income Tax Withheld
Social Security
FICA
Wage Garnishments
Credit Union
Other
Home Related Expenses
Mortgage or Rent
Second Mortgage
Third Mortgage
Real Estate Taxes
Insurance
Condo Fees &
Assessments
Mobile Home Lot Rent
Home Maintenance/
Upkeep
Utilities
Gas
Electric
Oil
Water/Sewer
Telephone:
Land Line
Cell
Cable TV
Internet
Other
Food
Eating Out
Groceries
Clothing
Laundry and Cleaning
Medical
Current Needs
Prescriptions
Dental
Insurance Co-Payments
or Premiums
LAST MO.
ACTUAL
$
THIS MO.
EXPECTED
$
THIS MO.
ACTUAL
$
ADJUSTED
MONTHLY
$
Other
Transportation
Auto Payments
Car Insurance
Gas and Maintenance
Public Transportation
Life Insurance
Alimony or Support Paid
School Expenses
Student Loan Payments
Entertainment
Newspapers/Magazines
Charity/Church
Pet Expenses
Amounts Owed on Debts
Credit Card
___________________
Credit Card
___________________
Credit Card
___________________
Medical Bill
___________________
Medical Bill
___________________
Other Back Bills
(List)
___________________
___________________
Cosigned Debts
Business Debts (List)
___________________
___________________
Other Expenses (List)
___________________
___________________
Miscellaneous
TOTAL
Other Important Debt Issues:
Wage Garnishments
Yes
No
Pending Court Cases
Yes
Pending Utility Shut-offs
No
Yes
No
Car Loan Defaults or Repossessions Tax Debts Yes
Student Loan Debts
Yes
No
Other:
Notes/Anticipated Changes:
Describe Assets and Other Resources:
Savings
Yes
No
Amount $
Court Cases Pending Against Others Yes
Value $
Anticipated Tax Refunds
Amount $
Yes
No
Assets Which Can Be Sold Yes
Value $
No
Pension or Retirement Funds
Value $
Other Assets and Notes:
Yes
No
No
No
INCOME AND EXPENSE TOTALS
Last Mo.
Actual
This Mo.
Expected
This Mo.
Actual
Adjusted
Expected
A. Total
Projected
Monthly Income
B. Total
Projected
Monthly
Expenses
Excess Income
or Shortfall
(A minus B)
Notes:
V. OTHER INFORMATION
1. Have client(s) made an effort to arrange a workout
on their own? What result?
2. Has the client filed bankruptcy? If so when?
Current status of case if still pending? If bankruptcy is
over, what result?
3.
Other issues which came up during interview.
4.
Questions and open issues that must be resolved.