Fillable Fannie Mae Form 1021 - Home Affordable Modification Program Hardship Affidavit (Page 2 of 4) in pdf

Information for Government Monitoring Purposes

The following information is requested by the federal government in order to monitor compliance

with federal statutes that prohibit discrimination in housing. You are not required to furnish this

information, but are encouraged to do so. The law provides that a lender or servicer may not

discriminate either on the basis of this information, or on whether you choose to furnish it. If

you furnish the information, please provide both ethnicity and race. For race, you may check more

than one designation. If you do not furnish ethnicity, race, or sex, the lender or servicer is required

to note the information on the basis of visual observation or surname if you have made this request

for a loan modification in person. If you do not wish to furnish the information, please check

the box below.

I do not wish to furnish this information

BORROWER

CO-BORROWER

Hispanic or Latino

Ethnicity:

Not Hispanic or Latino

American Indian or Alaska Native

Race:

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Female

Sex:

Male

Interviewer’s Name (print or type)

Name/Address of Interviewer’s Employer

To be Completed by Interviewer

This application was taken by:

Face-to-face interview

Interviewer’s Signature

Date

Mail

Telephone

Interviewer’s Phone Number (include area code)

Internet

Borrower/Co-Borrower Acknowledgement and Agreement

1. Under penalty of perjury, I/we certify that all of the information in this affidavit is truthful and

the event(s) identified above has/have contributed to my/our need to modify the terms of

my/our mortgage loan.

2. I/we understand and acknowledge the Servicer may investigate the accuracy of my/our

statements, may require me/us to provide supporting documentation, and that knowingly

submitting false information may violate Federal law.

3. I/we understand the Servicer will pull a current credit report on all borrowers obligated on the

Note.

4. I/we understand that if I/we have intentionally defaulted on my/our existing mortgage,

engaged in fraud or misrepresented any fact(s) in connection with this Hardship Affidavit, or

if I/we do not provide all of the required documentation, the Servicer may cancel the

Agreement and may pursue foreclosure on my/our home.

5. I/we certify that my/our property is owner-occupied and I/we have not received a

condemnation notice.

6. I/we certify that I/we am/are willing to commit to credit counseling if it is determined that

my/our financial hardship is related to excessive debt.

7. I/we certify that I/we am/are willing to provide all requested documents and to respond to all

Servicer communication in a timely manner. I/we understand that time is of the essence.

Fannie Mae Form 1021

Page 2 of 4

August 2009

Fannie Mae Form 1021 - Home Affordable Modification Program Hardship Affidavit Page 2

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