Foreclosure Assistance Request

Please Note:  You must be behind on your mortgage 3 months or more to qualify for our foreclosure mediation services.
 
Contact Information

* Required fields

*First Name:
*Last Name:
  Spouse Name:
  Employer:
  Spouse employer:
  Dependent(s) Ages:
*Phone:
  Second Phone:
*Email:
 
Address
*Address:
 
City:
State:
Zip:
Is this the house that is in foreclosure?     Yes No

Monthly Income
 
Your Monthly Take Home Pay::  $
Spouse Monthly Take Home Pay::  $
Other Income:  $

Mortgage Information
 
Year Purchased Home:   
Purchase Price of Home:  $
Last Refinanced: (What Year)   
1st Mortgage Balance:  $
Lender Name:   
Loan Number:   
What Type of Loan?   
Total Months Behind:   
2nd Mortgage Balance:  $
Lender Name:   
Loan Number:   
What Type of Loan?   
Total Months Behind:   
Taxes Included (Escrow)?     Yes No
Is There a Sale Date?     Yes No
If Yes, Please Enter Date   

Monthly Expenses

(a) 1st Mortgage Payment:  $
(b)2nd Mortgage Payment:  $
(c) Electricity Bill:  $
(d) Heating Bill:  $
(e) Water/Sewage:  $
(f) Telephone:  $
(g) Food (Monthly):  $
(h) Medical Drugs:  $
(i) Auto Insurance:  $
(j) Life, Health & other Insurance:  $
(k) Cable/Satellite TV  $
(l) Transportation (gas)  $
(m) Property taxes, if not included in mortgage:  $
(n) Alimony, Child Support  $
(o) Child care, College  $
(p) Automobile Payments  $
(q) Total Minimum Credit Card  Payments:  $
(r) Other:  $
Have You Filed a Bankruptcy?     Yes No
If Yes, What Type?   
(s) Chapter 13 Payments  $
 Cash on Hand:  $
*Best Time to call:   
Reason you are behind on Mortgage?