Universal Intake Form

STATE OF OREGON FORECLOSURE AVOIDANCE PROGRAM
UNIVERSAL INTAKE FORM
INSTRUCTIONS: Complete all sections of the form and attach copies of any required documents. You must provide a copy of the
completed form and documents to the Service Provider by the date stated in your Notice of Resolution Conference. You should also
bring a copy to the resolution conference and to any consultation with a housing counselor.
LOAN OR ACCOUNT NUMBER
LOAN SERVICER
BORROWER
CO-BORROWER
Borrower’s Name
Co-Borrower’s Name
Mailing Address
Mailing Address
Date of Birth
Date of Birth
Home Phone No.
Home Phone No.
Cell or Work No.
Cell or Work No.
INFORMATION ABOUT YOUR PROPERTY
Property Address (if same as mailing address, write “same”)
Is the property listed for sale?  Yes  No
Have you received housing counseling?  Yes  No
Have you received an offer?  Yes  No
If yes, please complete the following:
Date of offer:
Counselor’s Name:
Amount of offer: $
Agent’s Name:
Agency Name:
Agent’s Phone No.:
Counselor’s Phone No.:
For Sale by Owner?  Yes  No
Counselor’s Email:
Who pays the property tax bill for your property?
Who pays the hazard insurance premium for your property?
 I do
 I do
 Lender does
 Paid by condo or HOA
 Lender does
 Paid by condo or HOA
Are the taxes current?  Yes  No
Is the policy current?  Yes  No
Condo or HOA Fees?  Yes  No $
Insurance Company:
Paid to:
Insurance Co. Telephone No.:
Additional liens/mortgages or judgments on this property:
Lien Holder’s Name/Servicer
Balance
Contact Number
Loan Number
OTHER INFORMATION
I want:  Forbearance/repayment plan  Loan modification  Short sale  Deed-in-Lieu  Other (Describe):
The property is my:  Primary residence  Secondary residence  Investment
The property is:  Owner occupied  Renter occupied  Vacant
Have you filed for bankruptcy?  Yes  No
If yes:  Chapter 7  Chapter 13
Has your bankruptcy been discharged?  Yes  No
Form 610
V9-24-12 Page 1
Filing Date:
Bankruptcy Case No.:
1
INCOME AND ASSETS
Monthly Household Income
1
Household Assets
Monthly Gross Wages
$
Checking Account(s)
$
Overtime
$
Savings/Money Market
$
Child Support, Alimony,
3
Separation income
$
CDs
$
Social Security/SSDI
$
Stocks/Bonds
$
$
Other Cash on Hand
$
$
Other Real Estate (estimated
value)
$
Rental Income
$
Other:
$
Unemployment
$
Other:
$
Food Stamps/Welfare
$
Other:
$
Other (investment income,
royalties, interest, dividends,
etc.)
$
Other:
$
Total Monthly Gross Income
$
Pension, Annuity, Retirement
Income
Tips, Commissions, Bonuses,
Self-Employment Income
2
$
1
Include combined income from the borrower and co-borrower (if any).
Do not include the value of life insurance or retirement plans when calculating assets (e.g., 401k, pension funds, annuities, IRAs, Keogh plans, etc.
3
You are not required to disclose child support, alimony, or separation maintenance income unless you want to have that income considered by your servicer.
2
EXPENSES AND DEBTS
Monthly
Annual
Total Owing
First Mortgage Payment
$
$
Second Mortgage/Home Equity LOC Payment
$
$
Property Taxes (if not paid to lender)
$
$
Hazard Insurance (if not paid to lender)
$
$
Condo or HOA Fees
$
$
Car Payments
$
$
Car Insurance
$
$
Vehicle Gas and Maintenance
$
$
Credit Cards and Installment Loan Payments
$
$
Alimony and Child Support Payments
$
$
Child Care
$
$
Groceries
$
$
Utilities (gas, electric, water, sewer, garbage)
$
$
Communications (phone, internet)
$
$
Medical and Dental Expenses
$
$
$
Student Loan Payments
$
$
$
Other
$
$
$
Total Monthly Expenses/Debts
$
$
$
$
$
Other
Form 610
V9-24-12 Page 2
2
HARDSHIP AFFIDAVIT
I am requesting review under the Making Home Affordable program and any other loss mitigation program for which I may qualify. I
am having difficulty making my monthly payment because of financial difficulties created by (check all that apply and complete the
explanation section):
 My household income has been reduced. For example,
 My monthly debt payments are excessive and I am
unemployment, underemployment, reduced pay or hours,
overextended with my creditors. Debt includes credit cards,
decline in business earnings, death or disability, or divorce of a
home equity or other debt.
borrower or co-borrower
 My expenses have increased. For example, monthly mortgage  My cash reserves, including all liquid assets, are insufficient to
payment reset, high medical or health care costs, uninsured
maintain my current mortgage payment and cover basic living
losses, increased utilities or property taxes.
expenses at the same time.
 Other:
Explanation (or attach separate sheet of paper):
DOCUMENTS VERIFYING INCOME AND OCCUPANCY
You must provide to the Service Provider this completed form and all of the applicable documents described below on or before
the date stated in your Notice of Resolution Conference. If you fail to provide all required documents, your lender may not be
able to determine that you are eligible for a foreclosure avoidance measure. For each document you are providing, check the
appropriate box:

Paystubs (two most recent months)

Tax Returns (two most recent years)

Profit and Loss Statement (if self-employed, most
recent quarterly or year-to-date)

Bank Statements (two most recent months)

Benefits Statement or Letter from Provider (showing
amount, frequency and duration of social security,
disability, retirement, unemployment or other nonwage income)

Electric, heat, gas or other utility bill (most recent)
Divorce decree or separation agreement (if relying on
child support, alimony or maintenance payments)

Property Tax Statement or Appraisal/CMA (if available)

BORROWER ACKNOWLEDGEMENT
I/we represent the following:
1. That all of the information in this document is truthful to the best of my knowledge and belief.
2. I understand that the servicer will use the information in this document to evaluate my eligibility for a loan
modification or other foreclosure avoidance measure and may investigate the accuracy of my statements and
may request additional documentation, which I will provide.
______________________________________________________
Borrower Signature
_______________________________
Date
______________________________________________________
Co-Borrower Signature
_______________________________
Date
Form 610
V9-24-12 Page 3
3
INFORMATION FOR GOVERNMENT PROGRAM MONITORING PURPOSES
The following information is requested by the state 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 a 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:
 Not Hispanic or Latino
 Hispanic or Latino
Race:
 Native Hawaiian or Other Pacific Islander
 Black or African American
 Asian
 American Indian or Alaska Native
 White
Sex:

Female

Male
Form 610
V9-24-12 Page 4
Ethnicity:


Race:





Sex:


Not Hispanic or Latino
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
Black or African American
Asian
American Indian or Alaska Native
White
Female
Male
4