NAME (Last, First Middle):

SPOUSE (Last, First Middle):

PROPERTY CITY:

PROPERTY STATE:

Alabama Alaska AP Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas US Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

PROPERTY ZIP:

HOME TELEPHONE:

E-MAIL:

EMPLOYER:

WORK TELEPHONE:

SPOUSE’S EMPLOYER:

SPOUSE’S WORK TELEPHONE:

NUMBER OF DEPENDENTS

AGES OF DEPENDENTS

LOAN TYPE (FHA/VA/Conventional):

LENDER:

ACCOUNT NUMBER:

NUMBER OF MONTHS BEHIND:

MONTHLY  PAYMENT:

PURCHASE PRICE ($):

PURCHASE DATE (MONTH/YEAR):

01 02 03 04 05 06 07 08 09 10 11 12

Year 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

FILED BANKRUPTCY:

  Yes   No

FORECLOSURE SALE DATE:

SECOND MORTGAGE LENDER:

NUMBER OF MONTHS BEHIND:

SECOND MORTGAGE AMOUNT:

SECOND MORTGAGE MONTHLY PAYMENT:

REASON FOR DELINQUENCY:

 Loss of Income
 Separation
 Death in Family
 Illness
 Divorce
 Other

EXPLAIN OTHER REASON: