The first step to a successful mediation process is to work closely with a non-profit credit counselor.
If you have trouble completing the form or have questions, please call the Hotline at 888-xxx-xxxx to speak with a counselor. This is a free service and one we hope you will utilize in order to provide a more complete form.
The agency will work with the mediator to determine a course of action to assist you with your issue.
Borrower Information
* marked fields are mandatory
Homeowner Name *
Last: First:
First Mortgage Company *
Second Mortgage Company
First Mortgage Loan Number
Second Mortgage Loan Number
Contact Information
Home Phone *
- -
Cell Phone
- -
Work Phone *
- -
OK to text?
Preferred Call Method
Best Time to Call
Email Address *
The following 2 sections are optional. It asks for information regarding your financial hardship and your specific financial situation.
To skip the optional sections and submit contact information, complete section below.
Authorization
I Agree*
(Type Last Name)*
By checking this box and typing my last name, I certify that to the best of my knowledge the information I am submitting is accurate. I understand that submitting this information does not represent a suspension or delay in any ongoing legal processes related to my mortgage. Further, this submission of information does not guarantee a loan modification or any other solution related to my mortgage.
The Following 2 Sections are Optional.
A counselor will contact you to discuss your finances, and what your options are.
The following information will be discussed and can be provided in advance if desired.
Reason For Hardship
Reason #1
Reason #2 (If applicable)
Reason #3 (If applicable)
Do you plan to keep your home?
Yes No
Is this property your primary residence?
Yes No
Have you received a foreclosure notice?
Yes No
Have you filed for bankruptcy?
Yes No
Is the property listed for sale?
Yes No
Counseling Agency
Are you currently or have you been working with a counselor?
Yes No
Name of Counseling Agency (If Applicable)
Number for Counseling Agency (If Known)
- -
Financial Information
Total Gross Monthly Income
Total Monthly Take Home(Net Income)
To skip the optional sections and submit contact information, complete section below.
Authorization
I Agree*
(Type Last Name)*
By checking this box and typing my last name, I certify that to the best of my knowledge the information I am submitting is accurate. I understand that submitting this information does not represent a suspension or delay in any ongoing legal processes related to my mortgage. Further, this submission of information does not guarantee a loan modification or any other solution related to my mortgage.
This Section is Optional.
Expenses
Monthly Mortgage Payment
(First Mortgage)
Monthly Mortgage Payment
(Second Mortgage)
Monthly Homeowner's Insurance Payment (If not included in your monthly mortgage payment)
Monthly Property Taxes (If not included in your monthly mortgage payment)
Total Monthly Automobile Payment(s)
Total Minimum Monthly Credit Card Payment(s)
Total Monthly Child Support/Care Expenses
Total Monthly Medical Expenses
Total Monthly Grocery Expenses
Total Monthly Utilities Expenses
Total Monthly Phone/Cable Expenses
Total Monthly Transportation Expenses
Total Monthly Insurance Payments
Other Expenses
Authorization
I Agree*
(Type Last Name)*
By checking this box and typing my last name, I certify that to the best of my knowledge the information I am submitting is accurate. I understand that submitting this information does not represent a suspension or delay in any ongoing legal processes related to my mortgage. Further, this submission of information does not guarantee a loan modification or any other solution related to my mortgage.
Thank you.
A counselor will contact you to discuss your options.
It will help the counselor speed up the application process if you gather the following documents for review with the counselor.
You can fax these documents to us immediately at 1-888-xxx-xxxx
Generally, you will need the following:
For each borrower:
Two months of pay stubs or if self-employed, the Summary pages of the latest completed financials (Profit & Loss) from your business or latest 1040 tax return (principal 1040 pages only without schedules).
Two months of complete bank statements for all your banking and investments accounts.
Most recent Tax Return.
If your loan is Non-Escrowed, Proof of payment for recent property taxes, Homeowner’s Insurance and Homeowner’s Association Fees. (only required if the taxes and insurance are not collected as part of your monthly payment)
Proof of occupancy – Copy of recent utility bills (electricity, water, cable, etc.
A copy of a valid Florida Identification for each borrower.
Hardship Letter:
Brief written statement describing your hardship that will supplement an. The letter should detail the reason for your payment delinquency and request for relief.
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