Please provide the following contact information:

First Name
Last Name
Street Address
Address (cont.)
City
State
Zip Code
County
Phone
E-mail

List the names of the people responsible for repayment of the home loan and their dates of birth.

       Full name                                  Date of Birth      

Have you received any papers from the court about foreclosure? (Has a police officer or process server delivered to you a summons and complaint for foreclosure?)

Yes No

When is the best time to call you back on the phone?

How much is the monthly payment amount of your home loan?

If you are behind in your mortgage payments, how many months are you behind?

Which bank or lending company holds your mortgage?

Are you having financial difficulties because of a particular hardship such as the loss of a job, illness, or hospitalization? If so, please explain.

If you don't speak English, what language do you speak?

Do you need to be provided an interpreter? (Only check yes if you cannot use a family member for help.)

Yes No

When did you buy your home?

Do you claim homestead exemption on the property?

Yes No

Are you having problems with a first mortgage loan?

Yes No

Is the mortgage loan you are having trouble with an adjustable rate mortgage?

Yes No I Don't Know

If you called or wrote the lender or bank about these problems, what did they tell you to do?

Have you hired a lawyer to help you with any of this?

Yes No

What is your monthly household income? (Bring home.)

How many people live in your household?

For the purposes of data collection, is your ethnicity...?

Hispanic/Latino Non Hispanic/Latino

For the purposes of data collection, what is your race?

African American/black
Caucasian/white
Asian or Pacific Islander
Native American or Native Alaskan
Other/Multiracial

How did you find out about our Hotline?