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How did you hear about us:
First Name:
Last Name:
Spouses Full Name:
Address:
City:
State:
Zip:
Phone:
Cell Phone:
Email:
Property address:
Property City:
Property State:
Property Zip:
Employer:
Years in current Job:
Work Phone:
Part Time Employer:
Years in part time Job:
Spouse's Employer:
Spouse's years in Job:
Spouse's Work Phone:
Spouse's Part Time Employer:
Spouse's years in part time Job:
Number of family in household:
First Mortgage Lender:
Mortgage Loan Type:
Mortgage Loan Number:
Months Behind:
Second Mortgage Lender:
Months Behind:
Purchase Price:
Balance Owed:
Market Value of Home:
Value of Assets Owned:
Number of Payments Available:
Foreclosure Attorney:
Foreclosure Date:
Reason:
Notes/Comments:
Have you made any previous arrangements with your lender to settle the arrearages: Yes No
Debtor's Monthly Take Home Pay:
Spouse's Monthly Take Home Pay:
Other Monthly Take Home Pay:
Other Monthly Income: (child support, social security, disability income, etc)
Estimated Future Monthly Income:
Explanation of possible future monthly income:
Rent or Home Mortgage Payment:
Second rent or home mortgage payment:
Electricity bill:
Heating bill:
Water/Sanitation bill:
Telephone bill:
Newspapers bill:
Medical and Drug expenses:
Auto insurance:
Other insurance:
Cable television:
Transportation:
Taxes: (not deducted from wages)
Alimony, maintenance, or support:
Child care, School tuition:
Clothing:
Laundry and cleaning:
Religious and or charity:
Automobile payments:
Monthly credit card payments:
Chapter 13 payment:
Food:
Miscellaneous:

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