Contact Information
First Name:
Last Name:
Address:
City:
State:
Zipcode:
Work Phone:
Home Phone:
Email Address:
Housing and Credit Information
Type Of House:	Single Family Condo Townhouse Multi-Family Mobile Home with Land Mobile Home without Land Raw Land Agricultural Land Commercial Property
Current Value:
Original Purchase Price:
Total Mortgage Balance:
Current Interest Rate:
Fixed or Adjustable?:	Adjustable Fixed Not Sure
Monthly Payment:
Behind on Payments?:	Yes No
How would you rate your credit?:	Poor Fair Good Excellent
Best Time to Call:	8:00am-10:00am (home) 10:00am-12:00pm (home) 12:00pm-2:00pm (home) 2:00pm-4:00pm (home) 4:00pm-6:00pm (home) Evening (home) 8:00am-10:00am (work) 10:00am-12:00pm (work) 12:00pm-2:00pm (work) 2:00pm-4:00pm (work) 4:00pm-6:00pm (work)
Total Debt (excluding house):
Annual Income:
Type of Mortgage You Have:	Second Mortgage Debt Consolidation-Second Mortgage Debt Consolidation-Refinance 1st Home Improvement Refinance-Conventional Refinance-FHA Refinance-VA Purchase-Conventional Purchase-FHA Purchase-VA Commercial Reverse Mortgage Construction Home Equity Line of Credit
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Additional information
List the name of the Lender and the number of payments (if any) you are behind, and if a notice of default has been filed. Please indicate if your preference is to stay in your home or sell it. Also list any additional  information that may be helpful.