Foreclosure Mediation - Borrower Form printable pdf download

FORECLOSURE MEDIATION – BORROWER FORM

Within 5 days, please complete and return this form to us (by mail, e-mail, fax, or hand delivery)

YOUR PERSONAL INFORMATION IS COMPLETELY CONFIDENTIAL AND WILL NOT BE RELEASED

TO ANY OUTSIDE AGENCIES OR OTHER PARTIES. DEMOGRAPHIC DATA IS USED FOR STATISTICAL PURPOSES ONLY.

#1 Name: ____________________________________

Email: ______________________________________

Mailing Address: ______________________________

City/State/Zip: ______________________________

Cell: ___________________

Home Phone: ____________________

Work Phone: ___________________

 Email

 Cell

 Home Phone

 Work Phone

The best way to reach me is by:

Attorney: __________________________ Agency: _______________________ Phone: __________________

GENDER:  Female  Male

DATE OF BIRTH: __ __/__ __/__ __ __ __

AGE: _________

RELATIONSHIP STATUS:  Single  Partnered  Married  Separated  Divorced  Widowed

EMPLOYMENT STATUS:  Employed  Self-Employed  Part-Time  Unemployed  Retired

 Student

 Homemaker

 Military

 Disabled

 Temp. Disabled

ETHNIC BACKGROUND

NO. OF FAMILY MEMBERS IN HOUSEHOLD: _______

please check one;

if you are multi-ethnic, rank by numbers 1, 2, 3, etc.

ANNUAL HOUSEHOLD INCOME (before taxes,

starting with the 1 that you MOST identify with

total of all family members living in the house)

___ American Indian/Native American

please include: all earnings, unemployment, workers comp,

___ African American ___ Korean

social security, SSI disability, public assistance, veteran benefits,

___ Chinese

___ Samoan

survivor benefits, pension or retirement, alimony, child support,

___ Filipino

___ Tongan

etc. (Do not include food stamps or housing subsidies)

___ Hawaiian

___ Other Asian

 $0 - $10,000

 $82,001 - $100,000

___ Hispanic/Latino ___ Other Pacific Islander

 $10,001 - $20,000

 $100,001 - $150,000

___ Japanese

___ White/Caucasian

 $20,001 - $42,000

 $150,001 - $250,000

 $42,001 - $62,000

 $250,001 – $350,000

 $62,001 - $82,000

 Over $350,000

1) Besides yourself, who else is listed on the promissory note?

#2 Name: ________________________ Age: ____ Gender: ____ Ethnicity: _________ Income: ________

#3 Name: ________________________ Age: ____ Gender: ____ Ethnicity: _________ Income: ________

#4 Name: ________________________ Age: ____ Gender: ____ Ethnicity: _________ Income: ________

 YES

 NO

2) Have you applied for a loan modification?

Date documents were sent to the Lender:

____ /____ /____

 YES

 NO

3) Was your loan modification denied?

If YES, what was the reason given: ________________________________________________________



CONTINUED ON REVERSE

Foreclosure Mediation - Borrower Form

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