INTAKE FORM QUESTIONS

Please fill out as much information as possible. This will be kept strictly confidential in accordance with our privacy policy. Your information will help our counselors determine the best course for your financial future. if you dont have an answer for a specific field, simply skip it and move on to the next question. If you have any questions about this form please call us toll free at 877-844-7231.

ABOUT YOU
First Name:
Last Name:
Direct Email:
Direct Phone:
Best Time To Call:
Property Address:
Street address:
City:
State:
Zip:
How did you hear about THE FORECLOSURE CRISIS CENTER?
What is your immediate need?
ABOUT YOUR MORTGAGE
Have you received a Foreclosure notice?	Yes No
If yes, what date did you receive the notice?
Have you received notice of your Court Hearing Date?	Yes No (Note: This does not apply to all states)
If yes, when is the Court Hearing Date?
Have you received notice of A Sale?	Yes No
If yes, when is the Sale?
Is there anyone else on the current deed of record?	Yes No
If yes, who?
Have you had the home appraised recently?	Yes No
What was its appraised value?
Does it need any repairs?	Yes No
If yes, what repairs are needed?
Is the property vacant?	Yes No
If yes, For how long?
Who is the lender on the First Mortgage?
What do you owe on the First Mortgage?
What is your monthly payment on the First Mortgage?
Date of the last payment made on the First Mortgage?
Is this a fixed rate loan?	Yes No
Only applies to you if you have a Second Mortgage
Who is the lender on the Second Mortgage?
What do you owe on the Second Mortgage?
What is your monthly payment on the Second Mortgage?
Date of the last payment made on the Second Mortgage?
Second Mortgage: Is this a fixed rate loan?	Yes No
Only applies to you if you have other liens or property taxes
Do you have any liens that need to be paid?	Yes No
If yes, please list the lien or liens and how much you owe on them:

Do you have any property or IRS taxes that need to be paid?	Yes No
If yes, how much you owe on them:
Do you have any homeowners fees?	Yes No
How much are they per year?
Is your home currently for Sale?	Yes No
If yes, who is listing the property?
Your Financial Situation
Have you calculated your combined gross monthly income?	Yes No
What is your combined gross monthly income?
What is your current monthly expense total (including mortgage)?
How much credit card debt do you currently have (total)?
Have you requested a modification or forbearance on any loans or credit cards?	Yes No
Have you received any modification or forbearance (which loans)?	Yes No
Have you filed bankruptcy?	Yes No
If so, what chapter of bankruptcy?	7 13
If you have any additional comments or information you feel will help us evaluate your situation please include them below:

For a Free confidential counseling session:

INTAKE FORM QUESTIONS

ABOUT YOU

Property Address:

ABOUT YOUR MORTGAGE

Your Financial Situation