Form 1015 Mortgage Insurance Claim For Loss Page 2
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4________
38. Insurance Proceeds
________
39. Other Deductions (Attach Explanation)
________
40. Sub-Total Deductible Items (Total Lines 35 Through 39)
$
0.00
________
41. Total Claim Amount (Line 34 Minus Line 40)
$
________
42. Less Adjustments, if any (Attach Explanation)
$
________
43. Adjusted Claim Amount (Line 41 Minus Line 42)
$
44. Comments:
Claim Authorization:
I hereby certify that the statements contained herein are true, correct and complete. I understand that a claim will not be complete until all
applicable documents have been received by the Insurer. We are not aware of any facts indicating that the subject property is or might be
subject to any environmental contamination or hazard, except as disclosed in accompanying attachments.
_________________________
_________________________
45.
46.
Authorized Signature
Contact Name (Type or Print)
_________________________
____
____________________
47.
48.
(
)
Title/Department
Phone
________
49. ARM Interest Rate Information:
Unpaid Principal Balance (from line 25)
$
Rate
From
To
Number of Days
Amount
________
__
__
__
__
__
__
__________
________
1.
%
/
/
/
/
$
________
__
__
__
__
__
__
__________
________
2.
%
/
/
/
/
$
________
__
__
__
__
__
__
__________
________
3.
%
/
/
/
/
$
________
__
__
__
__
__
__
__________
________
4.
%
/
/
/
/
$
________
Total (enter on Line 26)
$
Expense Information:
Type
Date Paid
Description
Amount
__________
________________________________
________
50. Attorney’s Fee
$
__________
________________________________
________
$
__________
________________________________
________
$
__________
________________________________
________
$
________
Total (enter on Line 28)
$
__________
________________________________
________
51. Property Taxes
$
__________
________________________________
________
$
________
Total (enter on Line 29)
$
__________
________________________________
________
52. Hazard
$
__________
________________________________
________
Insurance
$
________
Premium
Total (enter on Line 30)
$
__________
________________________________
________
53. Prope rty
$
__________
________________________________
________
Preservation
$
__________
________________________________
________
Costs
$
__________
________________________________
________
$
__________
________________________________
________
$
__________
________________________________
________
$
________
Total (enter on Line 31)
$
__________
________________________________
________
54. Statutory
$
__________
________________________________
________
Disbursements
$
Fannie Mae
Form 1015 6/09
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