Load Modification Questionnaire
Please fill out this questionnaire concerning basic information about your situation.

How did you find us?		Please Select One ----> Referral Web Search News Reports Other
Borrower Name #1
Email:
Mailing Address:
Day Phone:
Evening Phone:
Employer:
Borrower Name #2
Email:
Mailing Address  (if different from Borrower #1):
Day Phone:
Evening Phone:
Employer:
Property Information
Property Address:
County Property Is In:
Primary Residence?		Yes No
Homeowners Insurance:
Property Tax Current?		Yes No
Loan Information
Date of Loan:
Original Loan Amount:
Current Interest Rate:
Do you escrow real estate taxes and homeowners insurance?
If yes, monthly amount:
Original Lender:
Original Servicer:
Current Servicer:
Payment Information
Are you current on the payments?		Yes No
Last payment made: date and amount
If you are not making payments, have you been setting that money aside?		Yes No
Loan Modification applied for (e.g., HAMP, HARP, other):
What is the current outstanding balance on your loan?
What is the assessed value of your house for real estate tax purposes?
Foreclosure status and scheduled date of sale:
Foreclosure notice published in newspaper?		Yes No
If yes, date of first notice publication:
Lender's attorney:
Brief description of why you are seeking assistance:
If you are behind in your payments, please list reasons why: