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   C O N F I D E N T I A L   
*Items marked with a red asterisk are required. If you're unable to answer a required question, give us your best guess or enter a "?", "NA", "0", "don't know", etc. If you have any problem submitting this form, please contact us and let us know.  Click here to use our Secure & Confidential Questionnaire.
Your Contact Information

*First Name(s)

*Day Phone

Example: 123 456-7890
*Last Name *Evening Phone
*Email Cellular Phone
    *Best Time to Call
Your Situation
*Has your lender started the foreclosure process on your home? Yes No
*What's your situation? How did you fall behind on your mortgage payments?
*Has a foreclosure sale date been set? If so, when?  
Your Property Information
*City *State *Zip
Property Type
*Square Footage
*Year Built
*Lot Size/Acres
*How long have you owned this house?
*What is the current condition of your property?
*What kind of repairs and maintenance does the house need?
*Who is currently living in the house?  
*Is the house currently listed with a ®Realtor? Yes No
          *If yes, how long has your house been for sale?   
Financial Information
Please provide the following information on your mortgage(s) and current financial situation...
    1st Mortgage   2nd Mortgage   3rd Mortgage
*Lender's Name         
*Balance $ $ $
*Payment $ $ $
*Payments Current? Yes No Yes No Yes No
*If No, how far behind? $ $ $
*How much are your total annual property taxes? $
*Are your property taxes and insurance included in your monthly payment? Yes No
*If your house were appraised, how much do you think it would be worth? $
*How much cash do you have to put towards stopping the foreclosure? $
*How much do you think you can afford to pay monthly, in addition to your current mortgage payment, to save your home? $
*How long can you afford to pay this monthly payment?   
*Are you currently in a Chapter 7 or 13 Bankruptcy? Yes No
*Are you currently capable of making your minimum monthly payments on all your debts? Yes No
*Do you have a 401K or whole life insurance policy? Yes No
*How did you hear about us?
Do you have any questions or comments you would like to share with us?
      Enter verification code (in red) to the left.
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Thank you for taking the time to share your information about your home with us.
We will review your information and contact you shortly.
If you have any problem submitting this form, please contact us and let us know.

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