Borrower Assistance Form Page 4
ADVERTISEMENT
1
2
3
4Borrower Name:
Loan number:
Describe in detail why you are having
MONTHLY EXPENSES
Borrower
Co-Borrower
trouble making your home loan
payment.
Other Home Loans, Rents & Liens
$
$
Auto Loan(s)
$
$
Auto: Insurance & Other Auto
$
$
Expenses
Credit Cards & Installment Loans
$
$
Health Insurance
$
$
Medical Expenses
$
$
Child Care, Child Support & Alimony
$
$
Food
$
$
Miscellaneous Spending Money
$
$
Utilities
$
$
Communications (Phone, Cell Phone,
$
$
Internet)
Other
$
$
$
-
$
-
TOTAL
I agree that the financial information provided is true and accurate as of the date set forth opposite my signature and that any intentional or negligent
misrepresentation of the information contained in this document may result in civil liability, including monetary damages, to any person who may suffer
any lose due to reliance upon the document, and/or in criminal penalties including but not limited to fine or imprisonment or both under the provisions of
Title 18 United State Code, Sec. 1001, et seq. I understand and acknowledge that any action taken by the lender is in strict reliance on the financial
information provided. My signature/acceptance below grants the holder of my mortgage or its designee the authority to confirm the information that I
have disclosed in this financial statement, to verify it as accurate by ordering a credit report, and to contact my realtor and/or credit counseling service.
By providing a cellular telephone number or email address, I consent to being contacted at the e-mail address or cellular or mobile telephone number
provided, and receiving autodialed and pre-recorded messages from the Servicer and its third party debt collectors.
I represent that ____I am ____I am not currently occupying the property securing the loan as my primary residence and that I intend to continue
occupying the property as my primary residence.
Borrower Signature
Date
Co- Borrower Signature
Date
Please make sure that all borrowers on the mortgage note have signed and dated this form.
If you have filed a bankruptcy petition and there is either an "automatic stay" in effect in your bankruptcy case or you have
received a discharge of your personal liability for the obligation identified in this letter, we may not and do not intend to pursue
collection of that obligation from you personally. If these circumstances apply, this notice is not and should not be construed to
be a demand for payment from you personally.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial