Fannie Mae Form 1021 - Home Affordable Modification Program Hardship Affidavit
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4Home Affordable Modification Program Hardship Affidavit
Borrower Name:
___________________________________ Date of Birth: ____________
Co-Borrower Name:
___________________________________ Date of Birth: ____________
Property Street Address: __________________________________________________________
Property City, ST, Zip:
__________________________________________________________
Servicer:
__________________________________________________________
Loan Number:
__________________________________________________________
In order to qualify for _____________________________’s (“Servicer”) offer to enter into an
agreement to modify my loan under the federal government’s Home Affordable Modification
Program (the “Agreement”), I/we am/are submitting this form to the Servicer and indicating by
my/our checkmarks (“”) the one or more events that contribute to my/our difficulty making
payments on my/our mortgage loan.
Borrower
Co-Borrower
Yes
No
Yes
No
My income has been reduced or lost. For example: unemployment,
underemployment, reduced job hours, reduced pay, or a decline in self-employed
business earnings. I have provided details below under “Explanation.”
Yes
No
Yes
No
My household financial circumstances have changed. For example: death
in family, serious or chronic illness, permanent or short-term disability,
increased family responsibilities (adoption or birth of a child, taking care of
elderly relatives or other family members). I have provided details below
under “Explanation.”
Yes
No
Yes
No
My expenses have increased. For example: monthly mortgage payment
has increased or will increase, high medical and health-care costs,
uninsured losses (such as those due to fires or natural disasters),
unexpectedly high utility bills, increased real property taxes. I have provided
details below under “Explanation.”
Yes
No
Yes
No
My cash reserves are insufficient to maintain the payment on my mortgage
loan and cover basic living expenses at the same time. Cash reserves
include assets such as cash, savings, money market funds, marketable
stocks or bonds (excluding retirement accounts). Cash reserves do not
include assets that serve as an emergency fund (generally equal to three
times my monthly debt payments). I have provided details below under
“Explanation.”
Yes
No
Yes
No
My monthly debt payments are excessive, and I am overextended with my
creditors. I may have used credit cards, home equity loans or other credit to
make my monthly mortgage payments. I have provided details below under
“Explanation.”
Yes
No
Yes
No
There are other reasons I/we cannot make our mortgage payments. I have
provided details below under “Explanation.”
Page 1 of 4
August 2009
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