Tell Us About Yourself

Tell us about yourself
Your Information
First Name*
Last Name*
Address*
City*
State*
Zip*
E-mail*
Best phone*
Cell and/or work phone*
Best time to call?*
Are you currently employed?*	Yes No
Have you filed for in the last 10 years bankruptcy?*	Yes No
If yes, was it Chapter 7 or 13?*	Chapter 7 Chapter 13
Tell us about your house
Property Information
How long have you currently lived in the house?*
What is the current condition of your property?*
If “needs repairs”, describe:
Who is currently living in the house?*
Is your house currently listed with a realtor?*	Yes No
If yes, how long has it been up for sale?
Tell us about your situation
Financial Information
How many months are you behind in mortgage payments?
Has a notice of default been filed*	Yes No
Is there a date for a trustee sale?*	Yes No
If yes, what is the date?
Please describe the reasons or circumstances surrounding your financial hardship?*
Lenders Name?
1st Mortgage?
Do you have a 2nd Mortgage?	Yes No
If Yes, what is the amount?
Original loan amount when you first bought the home?
What month and year did you get your latest mortgage?
Monthly payment?
Does this include taxes?	Yes No
If my house was appraised today it would be worth?
How did you hear about us?

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