Borrower First Name * Last Name * Address Line 1 * Address Line 2 City * State * AL AK AR AZ CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip * E-mail * Home Phone * Work Phone Property Estimated Property Taxes ($) Estimated Fair Market Value ($) Description of House and Condition First Mortgagee Mortgagee Name Mortgage Loan #: Address Line 1 Address Line 2 City State AL AK AR AZ CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Toll-Free Phone # FAX Contact's Name Contact's Direct Phone # Approximate Loan Balance ($) Date You Made Last Payment Monthly Payment ($) Taxes Included In Above Amount? Yes No Property In Foreclosure? Yes No Property Listed For Sale? Yes No Broker (If For Sale)? Currently In Bankruptcy? Yes No Briefly Describe What Caused The Default And What You Wish To Do Second Mortgagee Mortgagee Name Mortgage Loan # Address Line 1 Address Line 2 City State AL AK AR AZ CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Toll-Free Phone # FAX Contact's Name Contact's Direct Phone # Approximate Loan Balance ($) Date You Made Last Payment Monthly Payment ($) Taxes Included In Above Amount? Yes No Property In Foreclosure? Yes No Property Listed For Sale? Yes No Broker (If For Sale)? Currently In Bankruptcy? Yes No Briefly Describe What Caused The Default And What You Wish To Do