REQUEST FOR ASSISTANCE FORM

REQUEST FOR ASSISTANCE FORM
REQUEST FOR ASSISTANCE AND AFFIDAVIT FORM page 1
COMPLETE ALL THREE PAGES OF THIS FORM
Loan I.D. Number____________________________________
Servicer ____________________________________
BORROWER
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
I want to:
Keep the Property
Sell the Property
The property is my:
Primary Residence
Second Home
Investment
The property is:
Owner Occupied
Renter Occupied
Vacant
Mailing address
Property address (if same as mailing address, just write same)
E-mail address
Yes
No
_____________________
Agent’s Name: ___________________________________________
Agent’s Phone Number: ____________________________________
For Sale by Owner?
Yes
No
Have you contacted a credit-counseling agency for help
Yes
No
If yes, please complete the following:
Counselor’s Name: _________________________________________
Agency Name: ____________________________________________
Counselor’s Phone Number: __________________________________
Counselor’s E-mail: ________________________________________
Who pays the real estate tax bill on your property?
I do
Lender does
Paid by condo or HOA
Are the taxes current?
Yes
No
Condominium or HOA Fees
Yes
No $ __________________
Paid to: _________________________________________________
Who pays the hazard insurance premium for your property?
I do
Lender does
Paid by Condo or HOA
Is the policy current?
Yes
No
Name of Insurance Co.: ______________________________________
Insurance Co. Tel #: _________________________________________
Is the property listed for sale?
Yes
Yes
Has your bankruptcy been discharged?
No
No
Yes
If yes:
No
Chapter 7
Chapter 13
Filing Date:_________________________
Bankruptcy case number _________________________________
Additional Liens/Mortgages or Judgments on this property:
Lien Holder’s Name/Servicer
Balance
Contact Number
Loan Number
HARDSHIP AFFIDAVIT
My household income has been reduced. For example: unemployment,
underemployment, reduced pay or hours, decline in business earnings,
death, disability or divorce of a borrower or co-borrower.
My monthly debt payments are excessive and I am overextended with
my creditors. Debt includes credit cards, home equity or other debt.
My expenses have increased. For example: monthly mortgage payment
reset, high medical or health care costs, uninsured losses, increased
utilities or property taxes.
My cash reserves, including all liquid assets, are insufficient to maintain
my current mortgage payment and cover basic living expenses at the
same time.
Other:
Explanation (continue on back of page 3 if necessary): __________________________________________________________________________
______________________________________________________________________________________________________________________
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REQUEST FOR ASSISTANCE AND AFFIDAVIT FORM page 2
COMPLETE ALL THREE PAGES OF THIS FORM
INCOME/EXPENSES FOR HOUSEHOLD1
Monthly Household Income
Number of People in Household:
Monthly Household Expenses/Debt
Household Assets
Monthly Gross Wages
$
First Mortgage Payment
$
Checking Account(s)
$
Overtime
$
Second Mortgage Payment
$
Checking Account(s)
$
Child Support / Alimony /
Separation2
$
Insurance
$
Savings/ Money Market
$
Social Security/SSDI
$
Property Taxes
$
CDs
$
Other monthly income from
pensions, annuities or
retirement plans
$
Credit Cards / Installment
Loan(s) (total minimum
payment per month)
$
Stocks / Bonds
$
Tips, commissions, bonus
and self-employed income
$
Alimony, child support
payments
$
Other Cash on Hand
$
$
Other Real Estate
(estimated value)
$
$
Rents Received
Net Rental Expenses
Unemployment Income
$
HOA/Condo Fees/Property
Maintenance
$
Other _____________
$
Food Stamps/Welfare
$
Car Payments
$
Other _____________
$
Other (investment income,
royalties, interest, dividends
etc.)
$
Other ________________
_____________________
$
Do not include the value of life insurance or
retirement plans when calculating assets (401k,
pension funds, annuities, IRAs, Keogh plans, etc.)
Total (Gross Income)
$
Total Debt/Expenses
$
Total Assets
$
INCOME MUST BE DOCUMENTED
1Include combined income and expenses from the borrower and co-borrower (if any). If you include income and expenses from a household
member who is not a borrower, please specify using the back of this form if necessary.
2You are not required to disclose Child Support, Alimony or Separation Maintenance income, unless you choose to have it considered by your servicer.
INFORMATION FOR GOVERNMENT MONITORING PURPOSES
The following information is requested by the federal government in order to monitor compliance with federal statutes that prohibit discrimination in
housing. You are not required to furnish this information, but are encouraged to do so. The law provides that a lender or servicer may not
discriminate either on the basis of this information, or on whether you choose to furnish it. If you furnish the information, please provide both
ethnicity and race. For race, you may check more than one designation. If you do not furnish ethnicity, race, or sex, the lender or servicer is required to
note the information on the basis of visual observation or surname if you have made this request for a loan modification in person. If you do not wish
to furnish the information, please check the box below.
BORROWER
I do not wish to furnish this information
CO-BORROWER
I do not wish to furnish this information
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Race:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Race:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Sex:
Female
Male
Sex:
Female
Male
To be completed by interviewer
This request was taken by:
Face-to-face interview
Mail
Telephone
Internet
Name/Address of Interviewer’s Employer
Interviewer’s Name (print or type) & ID Number
Interviewer’s Signature
Date
Interviewer’s Phone Number (include area code)
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REQUEST FOR ASSISTANCE AND AFFIDAVIT FORM
page 3
COMPLETE ALL THREE PAGES OF THIS FORM
ACKNOWLEDGEMENT AND AGREEMENT
1. That all of the information in this document is truthful and the event(s) identified on page 1 is/are the reason that I
need to request a modification of the terms of my mortgage loan, short sale or deed-in-lieu of foreclosure.
2. I understand that the Servicer, the U.S. Department of the Treasury, or their agents may investigate the accuracy of my
statements and may require me to provide supporting documentation. I also understand that knowingly submitting false
information may violate Federal law.
3. I understand the Servicer will pull a current credit report on all borrowers obligated on the Note.
4. I understand that if I have intentionally defaulted on my existing mortgage, engaged in fraud or misrepresented any
fact(s) in connection with this document, the Servicer may cancel any Agreement under Making Home Affordable and
may pursue foreclosure on my home.
5. That: my property is owner-occupied; I intend to reside in this property for the next twelve months; I have not received
a condemnation notice; and there has been no change in the ownership of the Property since I signed the documents
for the mortgage that I want to modify.
6. I am willing to provide all requested documents and to respond to all Servicer questions in a timely manner.
7. I understand that the Servicer will use the information in this document to evaluate my eligibility for a loan modification
or short sale or deed-in-lieu of foreclosure, but the Servicer is not obligated to offer me assistance based solely on
the statements in this document.
8. I am willing to commit to credit counseling if it is determined that my financial hardship is related to excessive debt.
9. I understand that the Servicer will collect and record personal information, including, but not limited to, my name,
address, telephone number, social security number, credit score, income, payment history, government monitoring
information, and information about account balances and activity. I understand and consent to the disclosure of my
personal information and the terms of any Making Home Affordable Agreement by Servicer to (a) the U.S. Department
of the Treasury, (b) Fannie Mae and Freddie Mac in connection with their responsibilities under the Homeowner
Affordability and Stability Plan; (c) any investor, insurer, guarantor or servicer that owns, insures, guarantees or services
my first lien or subordinate lien (if applicable) mortgage loan(s); (d) companies that perform support services in
conjunction with Making Home Affordable; and (e) any HUD-certified housing counselor.
Borrower Signature
Date
Co-Borrower Signature
Date
HOMEOWNER’S HOTLINE
If you have questions about the program that your servicer cannot answer or need further counseling,
you can call the Homeowner’s HOPE™ Hotline at 1-888-995-HOPE (4673). The Hotline can help with questions about
NOTICE TO BORROWERS
Be advised that by signing this document you understand that any documents and information you submit to your servicer in connection with the Making
Home Affordable Program are under penalty of perjury. Any misstatement of material fact made in the completion of these documents including but not
limited to misstatement regarding your occupancy in your home, hardship circumstances, and/or income, expenses, or assets will subject you to potential
criminal investigation and prosecution for the following crimes: perjury, false statements, mail fraud, and wire fraud. The information contained in these
documents is subject to examination and verification. Any potential misrepresentation will be referred to the appropriate law
enforcement authority for investigation and prosecution. By signing this document you certify, represent and agree that:
“Under penalty of perjury, all documents and information I have provided to Lender in connection with the Making Home
Affordable Program, including the documents and information regarding my eligibility for the program, are true and correct.”
If you are aware of fraud, waste, abuse, mismanagement or misrepresentations affiliated with the Troubled Asset Relief Program,
please contact the SIGTARP Hotline by calling 1-877-SIG-2009 (toll-free), 202-622-4559 (fax), or www.sigtarp.gov. Mail can be sent
to Hotline Office of the Special Inspector General for Troubled Asset Relief Program, 1801 L St. NW, Washington, DC 20220.
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