Name

Address    

                ,      

Phone number    

Alternate phone number  

E-mail address   

Best time to reach you:   9am-12Noon       12Noon-3pm      3pm-6pm        6pm-9pm
                                          Other (enter comments at bottom)

How many payments have not been made?          1 2 3 4 5 6 7 8 9 or more 0

How many times have you been late on this mortgage?     1 2 3 4 5 or more

Have you ever had to obtain a written workout arrangement on this loan?   

How many loans do you have on this property?    Just One First and a second mortgage/line of credit 3 or more

Have you ever filed bankruptcy while you have had this mortgage?    Yes, Chapter 7 Yes, Chapter 13 Yes, both Chapter 7 and Chapter 13 No

how long ago did you last file BR?  

Is your income higher than your monthly living expenses?    Yes No, But I expect this to change in the next 90 days No, and I don't expect this to change any time soon Maybe, it depends

If there is an auction date scheduled, do you know what the date is?   

How would you like to see this situation resolved?            Fill in the blank, 500 characters or less

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