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Foreclosure Help Application Form

How did you hear about us? (If referred by someone, please type the name of the person who referred you.)

Salutation

Mr. Mrs. Ms. Miss

Your Name

Your Home Telephone Number

Your Cell Telephone Number

Your Work Telephone Number

How do you prefer to be contacted?

Home Telephone Cell Phone
Work Telephone

What is the best time of day to contact you?

At Home	By Cell Phone
At Work

Your Email Address

Are you currently late with any of your mortgage payments?

Yes No

If yes - how many payments have you missed including this month?

1^st Mortgage 2^nd Mortgage

Can you currently afford to pay all of your monthly bills and your mortgage payment(s)?

Yes No

Do you have a commitment to remain in your home?

Yes No

Please, briefly describe what event or events have occurred to cause you to fall behind on your mortgage payments.

Have you received any letters from your Mortgage Lender's attorneys or received any court documents?

Yes No

Is there a Foreclosure Sale date set for the sale of your home?

Yes No

If yes - what is the date of the Foreclosure Sale?

Month Day Year(MM-DD-YYYY)

Homeowner's Information:
Your Name
Is Your Name on the Mortgage?	Yes No
Your Spouse's / Other's Name
Is Your Spouse's / Other's Name on the Mortgage?	Yes No
How many Adults in your household How many Children in your household
Address Where You Live:
Street Address
City, State and Zip Code
Address of property behind on payments: (if same as above, please leave blank)
Street Address
City, State and Zip Code
Mortgage Lender's Name(s):
1st Mortgage Lender's Name
2nd Mortgage Lender's Name (if any)
Monthly Mortgage / Other Loan Payments:
1st Mortgage Payment	$
What type of loan is your 1st Mortgage? FHA VA Conventional Unknown
Are Real Estate Taxes and Homeowner's Insurance included with your Mortgage Payment?	Yes No
2nd Mortgage Payment (if any)	$
1st Automobile Loan Payment	$
2nd Automobile Loan Payment	$
Personal Loans / Student Loans and any Finance Company Payments (combined)	$
Credit Card Payments (combined)	$
Other Loan Payments	$
Other Monthly Payments: (please use the average monthly payment for each payment, thank you)
Monthly Food Expenses	$
Monthly Electric and Heating Bill Expenses (combined)	$
Monthly Water / Sewer / Garbage Expenses	$
Monthly Telephone Expense	$
Monthly Cell Phone Expense	$
Monthly Cable TV / Satellite Expense	$
Monthly Homeowner's Association or Condo Fees	$
Monthly Gasoline Expense	$
Monthly Public Transportation / Car Pooling and Parking Expenses	$
Monthly Automobile Insurance Expense	$
Monthly Clothing / Dry Cleaning Expense	$
Monthly Home Security / Home Alarm System	$
Monthly Day Care Expenses	$
Monthly Child Support Expenses	$
If you have Child Support Expenses - Is your Child Support Payroll Deducted? Yes No
Monthly Clubs / Sports / Gym and Hobby Expenses	$
Monthly Entertainment / Spending Money	$
Monthly Church Contributions	$
Monthly Prescription / Medical Expenses	$
Other Monthly Expenses	$
Other Monthly Expenses	$
Monthly Household Income:
Your Monthly Income (take home pay / net income)	$
Your Spouses or Other's Monthly Income (take home pay / net income)	$
Other Monthly Income	$
Other Monthly Income	$
Bankruptcy Information:
Have You Filed Bankruptcy Since You Bought Your Home?	Yes No
If Yes - Was the Bankruptcy Completed?	Yes No
Amount Behind / Money Saved:
Approximately how much money will it take to bring your mortgage payments current? $
How much money have you been able to save to give to your mortgage lender? $
I/WE hereby authorize the release of this information to United Capital Mortgage Assistance and its foreclosure prevention associates only, and therefore do not authorize the release of this information to any other person, person(s), corporation, entity or otherwise.
Your Name	Call me/us right away. Yes No