Home Affordable Modification Program Hardship Form

Home Affordable Modification Program Hardship Affidavit

Borrower Name: Date of Birth:

Co-Borrower Name: Date of Birth:

Property Street Address:

Property City, ST, Zip:

Servicer:

Loan Number:

In order to qualify for ’s (Servicer) offer to enter into an agreement to modify my loan under the federal government’s Home Affordable Modification Program (the Agreement), I/we am/are submitting this form to the Servicer and indicating by my/our checkmarks the one or more events that contribute to my/our difficulty making payments on my/our mortgage loan.

Information for Government Monitoring Purposes

The following information is requested by the federal 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 this request for a loan modification in person. If you do not wish to furnish the information, please check the box below.

Borrower I do not wish to furnish this information.      Co-Borrower I do not wish to furnish this information.

Ethnicity: Not Hispanic or Latino Hispanic or Latino
Ethnicity: Not Hispanic or Latino Hispanic or Latino

Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

Sex: Female Male
Sex: Female Male

To be Completed by Interviewer

Interviewer’s Name (print or type) Name/Address of Interviewer’s Employer

This application was taken by: [ ] Face-to-face interview [ ] Mail [ ] Telephone [ ] Internet

Interviewer’s Signature Date Interviewer’s Phone Number (include area code)

Borrower/Co-Borrower Acknowledgement and Agreement

1. Under penalty of perjury, I/we certify that all of the information in this affidavit is truthful and the event(s) identified above has/have contributed to my/our need to modify the terms of my/our mortgage loan.

2. I/we understand and acknowledge the Servicer may investigate the accuracy of my/our statements, may require me/us to provide supporting documentation, and that knowingly submitting false information may violate Federal law.

3. I/we understand the Servicer will pull a current credit report on all borrowers obligated on the Note.

4. I/we understand that if I/we have intentionally defaulted on my/our existing mortgage, engaged in fraud or misrepresented any fact(s) in connection with this Hardship Affidavit, or if I/we do not provide all of the required documentation, the Servicer may cancel the Agreement and may pursue foreclosure on my/our home.

5. I/we certify that my/our property is owner-occupied and I/we have not received a condemnation notice.

6. I/we certify that I/we am/are willing to commit to credit counseling if it is determined that my/our financial hardship is related to excessive debt.

7. I/we certify that I/we am/are willing to provide all requested documents and to respond to all Servicer communication in a timely manner. I/we understand that time is of the essence.

8. I/we understand that the Servicer will use this information to evaluate my/our eligibility for a loan modification or other workout, but the Servicer is not obligated to offer me/us assistance based solely on the representations in this affidavit.

9. I/we accept and agree to all terms of the Home Affordable Modification Trial Period (Trial Period) Plan which is incorporated herein by reference as if set forth in full.

10. I/we agree that when the Servicer accepts and posts a payment during the Trial Period it will be without prejudice to, and will not be deemed a waiver of, the acceleration of my loan or foreclosure action and related activities and shall not constitute a cure of my default under my loan unless such payments are sufficient to completely cure my entire default under my loan.

11. I/we agree that any prior waiver as to payment of escrow Items in connection with my loan has been revoked.

12. I/we agree to the establishment of an escrow account and the payment of escrow items if an escrow account never existed on my loan.

13. I/we understand that Servicer will collect and record personal information, including, but not limited to, my name, address, telephone number, social security number, credit score, income, payment history, government monitoring information, and information about account balances and activity. I understand and consent to the disclosure of my personal information and the terms of the Trial Period Plan and Modification Agreement by Servicer to (a) the U.S. Department of the Treasury, (b) Fannie Mae and Freddie Mac in connection with their responsibilities under the Homeowner Affordability and Stability Plan; (c) any investor, insurer, guarantor or servicer that owns, insures, guarantees or services my first lien or subordinate lien (if applicable) mortgage loan(s); (d) companies that perform support services for the Home Affordable Modification Program and the Second Lien Modification Program; and (e) any HUD certified housing counselor.

Explanation:

Explanation (continued)