How Did You Hear About Us?
Contact Information
Salutation
*
Mr.
Mrs.
Miss.
First Name
*
Last Name
*
Home Telephone Number
Cell Number
Work Number
Best Contact Number
Home Number
Cell Phone
Work Phone
Best Time of Day to Call
Daytime (8am - 5pm)
Evening (6pm - 9pm)
Weekends
Other
Email Address
Mortgage Information
1st Mortgage Lender's Name
What type of loan is your 1st Mortgage?
FHA
VA
Conventional
Adjustable Rate
Unknown
2nd Mortgage Lender's Name
Are you behind on your mortgage payments?
Yes
No
If Yes- How many payments have you missed including this month?
Can you currently AFFORD to pay all of your monthly bills and your mortgage payments?
Yes
No
Do you plan to remain in your home?
Yes
No
How long have you owned your home?
When did you last refinance your loan?
Briefly describe how you fell behind on your mortgage?
Have you received any letters from your lender or lender's attorneys or any court documents?
Yes
No
Is there a Foreclosure Sale Date set for the sale of your home?
Yes
No
If yes-what is the date of the Foreclosure Sale?
Homeowner's Information
Name of Borrower
Name of Co-Borrower
Current Address
Street Address
City, State and Zip Code
Address of Property behind on Payments (if same as above, please leave blank)
Street Address
City, State, and Zip Code
How many adults in the household?
How many children in the household
Monthly Mortgage/Other Loan Payments
1st Mortgage Monthly Payment
2nd Mortgage Payment (if any)
Are Real Estate taxes and Homeowner's Insurance included in your Mortgage payment?
Yes
No
1st Automobile Loan Payment
2nd Automobile Loan Payment
Personal Loans/Student Loans or any Finance Company Payments (combined)
Credit Card Payments (combined)
Other Loan Payments
Total Monthly Loan Payments
Other Monthly Payments: (please use the average monthly payment for each payment)
Monthly Homeowner's Association or Condo Fees
Monthly Home Security/Home Alarm System
Monthly Gasoline Expense
Monthly Automobile Insurance Expense
Monthly Public Transportation/Car Pool/Parking Expense
Monthly Food Expenses
Monthly Electricity Expenses
Monthly Heating/Natural Gas Expenses
Monthly Water/Sewer/Garbage Expenses
Monthly Telephone Expenses
Monthly Cell Phone Expense
Monthly Cable TV/Satellite Expense
Monthly Clothing/Dry Cleaning Expense
Monthly Day Care Espenses
Monthly Child Support Expenses
If you have Child Support Expense~Is your Child Support payroll deducted?
Yes
No
Monthly Clubs/Sports/Gym/Hobby Expenses
Monthly Entertainment/Spending Money
Montly Church Contributions
Monthly Prescription/Medical Expenses
Other Monthly Expenses
Other Monthly Expenses
Total Expenses
Monthly Household Income
Your Monthly Income (take home/net income)
Your Spouse's/Other's Monthly Income (take home/net income)
Other Monthly Income
Other Monthly Income
Total Income
Bankruptcy Information:
Have you filed bankruptcy since you bought your home?
Yes
No
If yes~was the bankruptcy completed?
Yes
No
Amount Behind/Money Saved:
Approximately how much money will it take to bring your mortgage payments current?
How much money have you been able to save to give to your mortgage lender?
I/We hereby authorize the release of this information to Mortgage Mitigation Services and its foreclosure prevention associates only, and therefore do not authorize the release of this information to any other person, persons(s), corporation, entity or otherwise.
Your Name
Call me/us right away.
Yes
No
