Request For Mortgage Assistance (Rma) Form Page 2
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4REQUEST FOR MORTGAGE ASSISTANCE (RMA) page 2
COMPLETE ALL FOUR PAGES OF THIS FORM
INCOME/EXPENSES FOR HOUSEHOLD
1
Number of People in Household:
Monthly Household Income
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/
Insurance
$
$
Savings/Money Market
2
Separation
Social Security/SSDI
$
Property Taxes
$
CDs
$
Stocks/Bonds
Other monthly income from
$
Credit Cards/Installment
$
$
pensions, annuities or
Loan(s) (total minimum
retirement plans
payment per month)
$
$
$
Other Cash on Hand
Tips, commissions, bonus
Alimony, child support
and self-employed income
payments
$
$
Other Real Estate
$
Rents Received
Net Rental Expenses
(estimated value)
HOA/Condo Fees/Property
$
$
$
Other _____________
Unemployment Income
Maintenance
$
$
$
Other _____________
Food Stamps/Welfare
Car Payments
$
$
Other ________________
Other (investment income,
Do not include the value of life insurance or
royalties, interest, dividends
_____________________
retirement plans when calculating assets (401k,
etc.)
pension funds, annuities, IRAs, Keogh plans, etc.)
Total (Gross Income)
$
Total Debt/Expenses
$
Total Assets
$
INCOME MUST BE DOCUMENTED
1
Include 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.
2
You 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
CO-BORROWER
I do not wish to furnish this information
I do not wish to furnish this information
Ethnicity:
Hispanic or Latino
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Not Hispanic or Latino
Race:
American Indian or Alaska Native
Race:
American Indian or Alaska Native
Asian
Asian
Black or African American
Black or African American
Native Hawaiian or Other Pacific Islander
Native Hawaiian or Other Pacific Islander
White
White
Sex:
Female
Female
Sex:
Male
Male
To be completed by interviewer
Name/Address of Interviewer’s Employer
This request was taken by:
Interviewer’s Name (print or type) & ID Number
Face-to-face interview
Interviewer’s Signature
Date
Mail
Telephone
Interviewer’s Phone Number (include area code)
Internet
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