Mac Form 710 - Uniform Borrower Assistance Form Page 15
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17Home Affordable Modification Program
Government Monitoring Data Form
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:
Ethnicity:
¨ Hispanic or Latino
¨ Hispanic or Latino
¨ Not Hispanic or Latino
¨ Not Hispanic or Latino
Race:
Race:
¨ American Indian or Alaska Native
¨ American Indian or Alaska Native
¨ Asian
¨ Asian
¨ Black or African America
¨ Black or African America
¨ Native Hawaiian or Other Pacific Islander
¨ Native Hawaiian or Other Pacific Islander
¨ White
¨ White
Sex:
Sex:
¨ Female
¨ Female
¨ Male
¨ Male
Name/Address of Interviewer's
To be completed by Servicers
Employer
This request was taken by:
Servicer/Interviewer's Name (print or
type) & ID Number
¨ Face-to-face interview
¨ Mail
¨ Telephone
¨ Internet
Servicer/Interviewer's Signature
Servicer/Interviewer's Phone
Number (include area code
Servicer/Interviewer's Fax Number
Servicer/Interviewer's email address
Loan Number: __
(include area code)
FannieMae/FreddieMac Form 710A
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024710910S0000
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