Universal Intake Form

STATE OF OREGON FORECLOSURE AVOIDANCE MEDIATION PROGRAM
UNIVERSAL INTAKE FORM

INSTRUCTIONS: Complete all sections of the form and attach copies of any required documents. You must provide a copy of the completed form and documents to the Mediation Service Provider by the date stated in your Mediation Scheduling Notice. You should also bring a copy to the mediation session and to any consultation with a housing counselor.

INFORMATION ABOUT YOUR PROPERTY

Property Address (if same as mailing address, write "same")

For Sale by Owner? Yes No

Additional liens/mortgages or judgments on this property:

OTHER INFORMATION

I want: Forbearance/repayment plan Loan modification Short sale Deed-in-Lieu Other (Describe):

The property is my: Primary residence Secondary residence Investment

The property is: Owner occupied Renter occupied Vacant

Have you filed for bankruptcy? Yes No If yes: Chapter 7 Chapter 13 Filing Date:

Has your bankruptcy been discharged? Yes No Bankruptcy Case No.:

INCOME AND ASSETS

EXPENSES AND DEBTS

HARDSHIP AFFIDAVIT

I am requesting review under the Making Home Affordable program and any other loss mitigation program for which I may qualify. I am having difficulty making my monthly payment because of financial difficulties created by (check all that apply and complete the explanation section):

My household income has been reduced.

For example, unemployment, underemployment, reduced pay or hours, decline in business earnings, death or disability, or divorce of a borrower or co-borrower

My monthly debt payments are excessive and I am overextended with my creditors. Debt includes credit cards, home equity or other debt.

My expenses have increased. For example, monthly mortgage payment reset, high medical or health care costs, uninsured losses, increased utilities or property taxes.

My cash reserves, including all liquid assets, are insufficient to maintain my current mortgage payment and cover basic living expenses at the same time.

Other:

Explanation (or attach separate sheet of paper):

DOCUMENTS VERIFYING INCOME AND OCCUPANCY

You must provide to the Mediation Service Provider this completed form and all of the applicable documents described below on or before the date stated in your Mediation Scheduling Notice. If you fail to provide all required documents, your lender may not be able to determine that you are eligible for a foreclosure avoidance measure. For each document you are providing, check the appropriate box:

Paystubs (two most recent months)

Profit and Loss Statement (if self-employed, most recent quarterly or year-to-date)

Benefits Statement or Letter from Provider (showing amount, frequency and duration of social security, disability, retirement, unemployment or other non-wage income)

Divorce decree or separation agreement (if relying on child support, alimony or maintenance payments)

Tax Returns (two most recent years)

Bank Statements (two most recent months)

Electric, heat, gas or other utility bill (most recent)

Property Tax Statement or Appraisal/CMA (if available)

BORROWER ACKNOWLEDGEMENT

I/we represent the following:

1. That all of the information in this document is truthful to the best of my knowledge and belief.

2. I understand that the servicer will use the information in this document to evaluate my eligibility for a loan modification or other foreclosure avoidance measure and may investigate the accuracy of my statements and may request additional documentation, which I will provide.

INFORMATION FOR GOVERNMENT PROGRAM MONITORING PURPOSES

The following information is requested by the state government in order to monitor compliance with federal statutes that prohibit discrimination in housing. You are not required to furnish this information, but are encouraged to do so. The law provides that a lender or servicer may not discriminate either on the basis of this information, or on whether you choose to furnish it. If you furnish the information, please provide both ethnicity and race. For race, you may check more than one designation. If you do not furnish ethnicity, race, or sex, the lender or servicer is required to note the information on the basis of visual observation or surname if you have made a request for a loan modification in person. If you do not wish to furnish the information, please check the box below.