Homeowner Assistance Form (Page 5 of 5) in pdf

Contacts — if you have questions

If you have questions about this document or your available options, please contact your home preservation specialist.

If you have questions about your options that your Servicer cannot answer or if you need further counseling, call the Homeowner’s HOPE™

Hotline at 1-888-995-HOPE (4673). A Hotline counselor will help you by answering questions about your available options and providing you

with free HUD-certified counseling services in English and Spanish.

Information for government monitoring purposes

For federal government programs, 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 and surname if you have made this request for assistance 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.

Hispanic or Latino

Ethnicity:

Not Hispanic or Latino

Race:

American Indian or Alaska Native

Race:

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Female

Sex:

Male

To be completed by interviewer

This application was taken by:

Face-to face interview

Mail

Telephone

Internet

Interviewer’s name (print or type)

Interviewer’s signature

Date

Interviewer’s phone number (include area code)

Name /Address of interviewer’s employer

Notice to Borrower

Be advised that you are signing this document under penalty of perjury. Any misstatement of material fact made in

the completion of these documents including but not limited to misstatement regarding your occupancy in your

home, hardship circumstances, and/or income will subject you to potential criminal investigation and prosecution

for the following crimes: perjury, false statements, mail fraud, and wire fraud. The information contained in these

documents is subject to examination and verification. Any potential misrepresentation will be referred to the

appropriate law enforcement authority for investigation and prosecution.

By signing the enclosed documents you certify, represent and agree that: “Under penalty of perjury, all documents

and information I have provided to Servicer in connection with this Agreement, including the documents and

information regarding my eligibility for mortgage assistance, are true and correct.”

If you are aware of fraud, waste, abuse, mismanagement or misrepresentations affiliated with the Troubled Asset

Relief Program, please contact the SIGTARP Hotline by calling 1-877-SIG-2009 (toll-free), 202-622-4559 (fax), or

Mail can be sent to Hotline Office of the Special Inspector General for Troubled Asset Relief

Program, 1801 L St. NW, Washington, DC 20220.

Homeowner Assistance Form (HAMP)

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Homeowner Assistance Form Page 5

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