|
About You:
There
is no obligation and it is free to apply. We will evaluate your application
and have a
response for you in 48 hours! (72 hours if you apply on a Saturday).
We work fast for you. |
Oath
of Confidentiality:
We hereby promise to protect all information as 100%
confidential. Your name or information will not be shared, stored, or
sold beyond the scope of providing help with your specific problem.
|
|
First Name: |
|
|
Last Name:
|
Home Phone: |
|
Middle Initial:
Birth Date: |
Work Phone: |
|
Street: |
City:
State: |
|
Zip: |
County:
|
|
Employer: |
Position: |
|
How Long There? |
Location: |
|
About Your Spouse |
|
|
First Name: |
|
|
Last Name: |
Home Phone: |
|
Middle Initial:
|
Work Phone: |
|
Employer: |
Position: |
|
How Long There? |
Location: |
|
Residence |
|
|
1st Mortgage: |
2nd Mortgage: |
|
How many
months behind are you? |
How many
months behind are you?" |
|
Monthly Payment: $ |
Monthly Payment: $ |
| Balance:
$ |
Balance:
$ |
| Original
Amount: $ |
Original
Amount: $ |
|
|
|
|
Loans and Charge Accounts
Secure Loans (i.e., Car Loans) |
|
| Creditor:
Balance: |
Mo.
Pmt $ Last Paid : |
| Creditor:
Balance: |
Mo.
Pmt $ Last Paid : |
| Creditor:
Balance: |
Mo.
Pmt $ Last Paid : |
|
Unsecured Loans (i.e., Credit Cards) |
|
| Creditor:
Balance: |
Mo.
Pmt $ Last Paid : |
| Creditor:
Balance: |
Mo.
Pmt $ Last Paid : |
| Creditor:
Balance: |
Mo.
Pmt $ Last Paid : |
| Creditor:
Balance: |
Mo.
Pmt $ Last Paid : |
| Creditor:
Balance: |
Mo.
Pmt $ Last Paid : |
| Creditor:
Balance: |
Mo.
Pmt $ Last Paid : |
|
Present Market Value: $
|
Total
Mortgage Balance: $ |
|
Amount Requested: $
|
|
|
Monthly Expenses |
|
| Mortgage
Payment(s): $ |
Property
Tax (if not inc.): $ |
| Groceries:
$ |
Electric
Bill: $ |
| Water
Bill: $ |
Cable
TV (sat, digital, etc): $ |
| Life,
Health Insurance: $ |
Auto
Insurance: $ |
| Gasoline:
$ |
Child
Support: $ |
| Day
Care: $ |
Clothing/Misc:
$ |
| Periodic
Expenses: $ |
Other:
$ |
|
Monthly Income |
|
| Husband:
$ |
Other:
$ |
| Wife:
$ |
Other:
$ |
|
Questionnaire |
Please
check the event/s that caused you to fall behind on your mortgage: |
| Temporary
Lay-off |
Job
Loss |
| Reduction
in Hours |
Too
many other bills |
| Illness/Injury
|
Divorce/Separation
|
| Expensive
Repairs |
Other:
|
|
Please
briefly describe the events that caused you to fall behind on your
mortgage
|
Have
you ever declared bankruptcy?
Yes No |
If
so, was it completed?
Yes No |
| Date
of discharge: |
|
|
How
much does the mortgage company say is due to get the mortgage current? |
|
How
much money do you have available to go to the mortgage right now? |
|
If your mortgage company required you to make a house payment, how long would it take for you to have one available?
|
If
we help you get caught up, do you promise to pay your mortgage as your
highest priority?
Yes No |
| I
hereby attest that all items are accurate and true. I authorize
the release of all information contained on this web page to Home Savers
USA, Inc.
First
Middle Initial: Last:
Your E-mail Address:
Call me Now
yes
no
Best Time To Call:
|
