Foreclosure Mediation - Borrower Form (Page 2 of 2) in pdf

Foreclosure Mediation - Borrower Form Page 2

 YES

 NO

4) Is there a second mortgage or other lien on the property?

If YES, with whom: ____________________________________________________________________

 YES

 NO

5) Has your financial situation improved recently?

If YES, please explain: __________________________________________________________________

 YES

 NO

6) Are there any family members who could help you financially?

If YES, please explain: __________________________________________________________________

7) I am interested in exploring the following options: (see enclosed glossary)

 Loan modification

 Short sale

 Deed in lieu

 Other: ____________________________________________________________________________

8) I understand that in order to be considered for the above options I am required

by the court to make an appointment with a certified housing counselor

 YES

(refer to the document “Steps to Foreclosure Mediation”):

 YES

9) I understand there is a $100 subsidized fee *, payable to Ku‘ikahi Mediation Center:

* An additional $200 (of the total $300 fee) is being subsidized by grant funds from the Foreclosure Assistance Program

administered by the Hawai‘i Department of the Attorney General

PAYMENT ENCLOSED ($100):

 Check to “Ku‘ikahi Mediation Center”, 101 Aupuni Street, Suite PH 1014 B-2, Hilo HI 96720

 Visa

 MasterCard

_____________________________________

________________ ________________

Card Number

Expiration Date

Security Code

_____________________________________

____________________________________

Name (as it appears on the card)

Signature

rev. 2/12/2016

Foreclosure Mediation - Borrower Form Page 2