Detail Intake Form

To assist us in providing you with the most effective and efficient evaluation, please complete the  intake form as thoroughly as possible.  A counselor will review your information and will contact you shortly to discuss your options.

Your Privacy is important to us.

Alternatives to Foreclosure Detailed Intake Form

Date *
Email *
First Name *
Middle Name
Last Name *
Address *
City *
State/Region *
Zip/Postal Code *
Home Phone *
Cell
Primary Borrowers SS# *
Date of Birth *
Enter Description Here
Race *	1. White/Caucasian 2. Black/African American 3. American Indian/Alaskan Native 4. Asian 5. Native Hawaiian/Other Pacific Islander 6. Other
Explain other Race
Hispanic *	YES NO
Marital Status *	1. Single 2. Married 3. Divorced 4. Separated 5. Widowed
Gender *	MALE FEMALE
Disabled *	YES NO
Education *	1. Below High School Diploma 2. High School Diploma or Equivalent 3. Two-Year College 4. Bachelor’s Degree 5. Master’s Degree 6. Above Master’s Degree
CO-BORROWER INFORMATION
Co-Borrowers First Name
Co-Borrowers Middle Name
Co-Borrowers Last Name
Co-Borrowers SS#
Co-Borrower Date of Birth
Co-Borrowers Race	1. White/Caucasian 2. Black/African American 3. American Indian/Alaskan Native 4. Asian 5. Native Hawaiian/Other Pacific Islander 6. Other
Is co-borrower Hispanic?	YES NO
Co-Borrower Marital Status	1. Single 2. Married 3. Divorced 4. Separated 5. Widowed
Co-Borrowers Gender	MALE FEMALE
Is co-borrower disabled?	YES NO
Co-Borrowers Education	1. Below High School Diploma 2. High School Graduate or Equivalent 3. Two Year College 4. Bachelor’s Degree 5. Master’s Degree 6. Above Master’s Degree
Relationship to Primary Borrower	SPOUSE CHILD SIBLING PARENT SIGNIFICANT OTHER(Girl/Boyfriend) OTHER
EMPLOYMENT
Primary’s Employer *
Position
Hire Date *
Employer Phone Number *
Net Income (AFTER Taxes) *
How often paid? *	WEEKLY BI-WEEKLY TWICE A MONTH MONTHLY COMMISSION OTHER
Co-Borrower Primary Employer
Co-Borrowers Position
Co-Borrowers Hire Date
Co-Borrowers Employer Phone Number
Co-Borrowers Net Income (AFTER Taxes)
How often is co-borrower paid?	WEEKLY BI-WEEKLY TWICE A MONTH MONTHLY COMMISSION OTHER
PROPERTY INFORMATION
1st Mortgage Servicer/Bank *
Loan Number *
Current Interest Rate
Interest Rate Type *	FIXED ADJUSTABLE INTEREST ONLY OPTION ARM NOT SURE
Principal Balance $ *
Monthly Payment $ *
2nd Mortgage Servicer/Bank
Loan Number – 2nd
Current Interest Rate – 2nd
Interest Rate Type – 2nd	FIXED ADJUSTABLE INTEREST ONLY OPTION ARM UNSURE
Principal Balance – 2nd Loan $
Monthly Payment – 2nd Loan $
EXPLANATION OF FINANCIAL HARDSHIP
My financial situation is *	Temporary Permanent
Explanation of Financial Hardship: *
FINANCIAL STATEMENT
Net Income Borrower *
Net Income Co-Borrower *
Other Household Members Net Income *
Rental Income *
Child Support/Alimony Income *
Disability/Social Security Income *
TOTAL Household Income (ADD all income fields) *
Assets – Checking Accounts *
Assets – Savings Accounts *
Assets – IRA/401K/Keogh Accounts *
TOTAL Assets (ADD all asset fields) *
Expenses – 1st Mortgage *
Expenses – 2nd Mortgage *
Expenses – Other Mortgage/Liens/Rents *
Expenses – Home Owners Insurance *
Expenses – Homeowners Association Dues *
Expenses – Property Tax *
Expenses – Other Insurance Life/Health *
Expenses – Transportation (gas/insurance) *
Expenses – Total Auto Loan(s) *
Expenses – Total Installment Loan(s) *
Expenses – Credit Card #1 *
Expenses – Credit Card #2 *
Expenses – Credit Card #3 *
Expenses – Credit Card #4 *
Expenses – Child Care *
Expenses – Electric *
Expenses – Gas/Oil *
Expenses – Water *
Expenses – Home Phone/Cable/Internet *
Expenses – Cell Phone *
Expenses – Groceries/Dining out *
Expenses – Other *
SUMMARY
TOTAL Income (add all incomes) *
TOTAL Expenses (add all expenses) *
Surplus+/Deficit (subtract expense from income) *
Have you been denied a loan modification? *	YES NO
Reason for loan modification denial
What type of evaluation are you requesting? *	SHORT SALE DEED IN LIEU LOAN MODIFICATION ALL OPTIONS NOT SURE
Is this your primary residence? *	YES NO
Months Behind:
Original Purchase Price: *
Today’s Approximate Market Value *
Have you ever refinanced to cash out? *	YES NO UNSURE
Total amt of cash out refinance (all transactions)
Any of these loans a Home Equity Line of Credit? *	YES NO UNSURE
Total amt of Home Equity Lines of Credit
Were any of the funds used to improve property? *	YES NO
Amount of total improvements
*IMPORTANT NOTICE: BY SENDING THIS INFORMATION, I/WE CERTIFY THAT THE INFORMATION AND DOCUMENTATION PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY/OUR KNOWLEDGE. IN THE EVENT A THIRD PARTY IS DESIGNATED TO ASSIST ON MY/OUR BEHALF, I/WE WILL INCLUDE WRITTEN AUTHORIZATION TO THE DESIGNEE TO ASSIST ON MY/OUR BEHALF. I/WE ACKNOWLEDGE THAT R.E.S.C.U.E. IS ONLY ACTING A S NON-PROFIT AGENCY, PROVIDING GENERAL ANSWERS TO GENERAL QUESTIONS AND IS NOT INTENDED AS A SUBSTITUTE FOR INDIVIDUAL LEGAL ADVICE. ADVICE IN SPECIFIC SITUATIONS MAY DIFFER DEPENDING UPON A WIDE VARIETY OF FACTORS.
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