Homeowner Assistance Form (Page 4 of 5) in pdf

Acknowledgment and Agreement

I/We understand that I/we will be considered for all mortgage assistance options available to us, including federal government programs as

appropriate. I/We certify as follows:

1. That all of the information in this affidavit is true and accurate and the event(s) identified on page two is/are the reason that I/we need to

request a modification of the terms of my/our mortgage, short sale or deed in lieu of foreclosure.

2. I/We understand that the Servicer, the U.S. Department of the Treasury, or its agents may investigate the accuracy of my/our statements, may

require me/us to provide supporting documentation, and that knowingly submitting false information may violate federal law and may result

in foreclosure.

3. I/We understand the Servicer may pull a current credit report on all borrowers obligated on the Note.

4. I/We understand that if I/we have intentionally defaulted on my/our existing mortgage, engaged in fraud or misrepresented any fact(s) in

connection with this document, the Servicer may cancel any Agreement and may pursue foreclosure on my/our home and/or pursue any

available legal remedies.

5. I/We understand, to be considered for certain federal government programs my/our property must be owner-occupied. If I/we have not

indicated otherwise on this form, I/we certify that: my/our property is owner-occupied and I/we intend to reside in this property for the next

twelve months and I/we have not received a condemnation notice and there has been no change in the ownership of the property since

I/we signed the documents for the mortgage that I/we want to modify.

6. I/We am/are willing to provide all requested documents and to respond to all Servicer questions in a timely manner.

7. I/We understand that the Servicer will use the information in this document to evaluate my/our eligibility for a loan modification or short sale

or deed in lieu of foreclosure, but the Servicer is not obligated to offer me/us assistance based solely on the statements in this document.

8. I/We am/are willing to commit to credit counseling if it is determined that my/our financial hardship is related to excessive debt.

9. If I/we am/are eligible for a trial period plan, repayment plan, or forbearance plan, and I/we accept and agree to all terms of such plan, I/we

also agree that the terms of this Acknowledgment and Agreement are incorporated into such plan by reference as if set forth in such plan in

full. My/Our first timely payment following my/our Servicer’s determination and notification of my/our eligibility or prequalification for a

trial period plan, repayment plan, or forbearance plan (when applicable) will serve as acceptance of the terms set forth in the notice sent to me

that sets forth the terms and conditions of the trial period plan, repayment plan, or forbearance plan.

10. I/We agree that when the Servicer accepts and posts a payment during the term of any repayment plan, trial period plan, or forbearance plan it

will be without prejudice to, and will not be deemed a waiver of, the acceleration of my/our loan or foreclosure action and related activities and

shall not constitute a cure of my/our default under my/our loan unless such payments are sufficient to completely cure my/our entire default

under my/our loan.

11. I/We agree that any prior waiver as to my/our payment of escrow items to the Servicer in connection with my/our loan has been revoked.

12. If I/we qualify for and enter into a repayment plan, forbearance plan, and trial period plan, I/we agree to the establishment of an escrow

account if an escrow account never existed on my/our loan as required.

13. I/We understand that the Servicer will collect and record personal information, including, but not limited to, my/our name(s), address,

telephone number, Social Security number(s), credit score, income, payment history, government monitoring information, and information

about account balances and activity. I/We understand and consent to the disclosure of my/our personal information to (a) the U.S.

Department of the Treasury or its agents; (b) any investor, insurer, guarantor or servicer that owns, insures, guarantees or services my/our

first lien or subordinate lien (if applicable) mortgage loan(s); (c) companies and/or individuals that perform support services in conjunction

with home preservation mortgage assistance efforts; (d) auditors, including but not limited to independent auditors, regulators and agencies;

and (e) any HUD-certified housing counselor.

I/We consent to being contacted concerning this request for mortgage assistance at any cellular or mobile telephone number I/we have

provided to the Servicer. This includes text messages and telephone calls to my/our cellular or mobile telephone.

(Borrower signature) (Date)

(Co-borrower signature) (Date)

Homeowner Assistance Form (HAMP)

RFDocType 50431

Page 4 of 5

29290MU 11/11

BARCODE

Homeowner Assistance Form Page 4

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