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.
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