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Mortgage Counseling

Please complete this intake form to help us determine whether or not you qualify for a loan modification or other housing loss prevention strategies. (Important note: If you submitted this form between 9/28/11 to 10/6/11, technical problems may have stopped it from going through. Please try again.) Completing this form will require you to fill in some personal information about your financial situation. All fields marked with an asterisk (*) are required. The information we request is required by the federal, state and local organizations that provide our funding and allow us to offer our services at no cost. It will also assist our mortgage counselors in assessing your situation to determine what options may be available for you. All information will remain confidential in accordance with HUD and Solid Ground guidelines.
* indicates a required field

First Name *


Last Name *


Street Address *


City *


State *


Zip Code *


County


Area Code + Home or Cell Phone # *


Work Phone #


Email *


Referred by


How many people live in your house? *



Is anyone in your household receiving
disability benefits? *

Is anyone in your household a veteran or currently
active in the military? *


If yes, who?

What is your race/ethnicity?


Your Date of Birth? *

Is English your primary language? *


If no, would you like an interpreter?

For what language?


Income

Current Gross Monthly Household Income *(income before taxes or other deductions are taken out):

$

Main Income Source *


Do you have a plan for increasing your income or resources to bring your loan current?

Have you contacted your lender or servicer?

If yes, check one of the following:

Hardship

What caused you to fall behind? *



Is the situation that caused late payment resolved?

Do you have money saved?


If yes, how much?

$
First Mortgage

Monthly Payment *

$

Interest Rate *

%

Is this an interest-only loan?

Status of Loan

Type of Loan

Payment include taxes and insurance?

If no, are you current on your property taxes?

Adjustable Rate Mortgage (ARM) *

Has interest rate adjusted?


If no, when will the loan adjust?


If yes, was the loan affordable before adjustment?

Lender/Servicer *


# of Months Behind? *


Total Amount Past Due?

$

Principle Balance  *

$

Value of Home

$

Year of Home Purchase


Notices:

Default


Sale


Date Received


Sale Date

Second Mortgage

Monthly Payment

$

Interest Rate

%

Is this an interest-only loan?

Lender/Servicer


# of Months Behind?


Total Amount Past Due?

$

Principle Balance

$

Years in Loan


Notices:

Default


Sale


Date Received


Sale Date

Please answer the following required questions, then click SUBMIT (or CANCEL to exit form without submitting):

Is your mortgage payment less than 67% of your gross monthly income (before taxes)? (To find out, divide your mortgage payment into your gross monthly income.) *


If Unemployment Compensation is a source of income for your household, do you have any additional sources of household income? *


Is the home at risk of foreclosure your primary residence? *