Form 1015 Mortgage Insurance Claim For Loss Page 3
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4__________
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$
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$
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$
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Total (enter on Line 32)
$
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55. Other
$
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Disbursements
$
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$
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$
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$
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$
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Total (enter on Line 33)
$
56. Required Enclosures:
Additional Enclosures (If Applicable):
Evidence of Good and Merchantable (or Marketable) Title
Rent or Receiver Account History
Loan Payment History
Bankruptcy Documents
Expense Documentation
Buydown Agreement
Copy of Original Note
Assumption Agreement
Copy of Original HUD-1 Statement
Closing Statement From Most Recent Sale
Copy of Documents Commencing Foreclosure
Documents Pertaining to Preservation and/or
Establishment of Deficiency Judgment
Copy or Primary MI Claim for Loss and Settlement Check
_________________________
57. Is property
vacant or
occupied?: If occupied, please state name of occupant:
__________________________
____
__________________
Key to property may be obtained from
Telephone (
)
For your protection California law requires the following to appear on this form: ANY PERSON WHO KNOWINGLY
PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE
SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON.
The following statement applies to insured parties residing in and to those who make claims with respect to insured
loans secured by properties located in New York: ANY PERSON WHO KNOWINGLY AND WITH THE INTENT TO
DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR
STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS, FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A
FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SHALL BE ALSO SUBJECT TO A CIVIL PENALTY OF UP
TO $5,000 AND THE STATED VALUE OF EACH CLAIM.
Other states have laws that apply to insured parties and to those who make claims with respect to properties located
in their respective areas which: MAKE IT A CRIME FOR PERSONS WHO KNOWINGLY AND WITH INTENT TO
INJURE, DEFRAUD OR DECEIVE ANY INSURANCE COMPANY, FILE A STATEMENT OF CLAIM CONTAINING
FALSE, INCOMPLETE OR MISLEADING INFORMATION. SUCH PERSONS ARE SUBJECT TO CRIMINAL AND CIVIL
PENALTIES INCLUDING PROSECUTION AND PUNISHMENT FOR INSURANCE FRAUD WHICH MAY BE A FELONY.
PENALTIES MAY INCLUDE FINES, IMPRISONMENT AND/OR DENIAL OF INSURANCE BENEFITS. OUR FINDINGS
MUST BE REPORTED TO THE APPLICABLE REGULATORY AGENCY IF REQUIRED.
Fannie Mae
Form 1015 6/09
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