Homeowner Assistance Form

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Before you complete this form,
Homeowner Assistance Form
contact us for assistance.
Mortgage loan number:
I/We want to:
Keep the property
Sell the property
The property is my/our:
Primary residence
Second home
Investment property
The property is:
Owner occupied
Renter occupied
Vacant
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
Home phone number
(
)
(
)
Cell phone number
Cell phone number
(
)
(
)
Work phone number
Work phone number
(
)
(
)
Email address
Email address
Mailing address
Mailing address (if different than borrower’s)
Property information
Property address (if same as mailing address, write “same”)
Number of people who live in the home
Is this property listed for sale?
Yes
If yes, what was property listing date? ___________________
No
Have you received an offer on the property?
Yes
Date of offer ____________ Amount of offer $___________
No
Agent/agency name______________________
Agent/agency phone number (
)__________________________
For sale by owner?
Yes
No
Who pays the real estate tax bill on your property?
I/We do
Servicer does
Are the taxes current?
Yes
No
Condominium or homeowners association fee?
Yes $________
Paid to (Name & Address)____________________
No
Who pays the homeowners insurance policy for your property?
I/We do
Servicer does
Paid by condominium or homeowners association
Is the policy current?
Yes
No
Name of insurance company _____________________
Insurance company phone number (
)_____________________
If there are additional liens/mortgages or judgments on this property, name the person(s), company or firm and phone
number(s).
Lien holder's name/Servicer________________ Phone number (
)__________ Loan number ___________ Balance
$____________
Lien holder's name/Servicer________________ Phone number (
)__________ Loan number ___________ Balance
$____________
Borrower/co-borrower situation
Have you contacted a credit-counseling agency for help?
Yes
No
If yes, complete counselor contact information below.
Counselor’s name _____________________________
Counselor’s phone number (
) ___________________________
Counselor’s email _____________________________
Homeowner Assistance Form (HAMP)
RFDocType 50431
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29290MU 11/11
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