Intake Questionnaire – W
Property Type
*
Single Family Residence
Mobile Home with Land
Mobile Home without Land
Condominium
Town House
Multi-Family
Commercial
Vacant Land
Estimated Value Of Your Home
*
$50,000
$55,000
$60,000
$65,000
$70,000
$75,000
$80,000
$85,000
$90,000
$95,000
$100,000
$105,000
$110,000
$115,000
$120,000
$125,000
$130,000
$135,000
$140,000
$145,000
$150,000
$155,000
$160,000
$165,000
$170,000
$175,000
$180,000
$185,000
$190,000
$195,000
$200,000
$205,000
$210,000
$215,000
$220,000
$225,000
$230,000
$235,000
$240,000
$245,000
$250,000
$275,000
$300,000
$325,000
$350,000
$375,000
$400,000
$425,000
$450,000
$475,000
$500,000
$525,000
$550,000
$575,000
$600,000
$625,000
$650,000
$675,000
$700,000
$725,000
$750,000
$775,000
$800,000
$825,000
$850,000
$875,000
$900,000
$925,000
$950,000
$975,000
$1,000,000
$1,025,000
$1,050,000
$1,075,000
$1,100,000
$1,125,000
$1,150,000
$1,175,000
$1,200,000
$1,225,000
$1,250,000+
Estimated Total Loan Amount Owed
*
$50,000
$55,000
$60,000
$65,000
$70,000
$75,000
$80,000
$85,000
$90,000
$95,000
$100,000
$105,000
$110,000
$115,000
$120,000
$125,000
$130,000
$135,000
$140,000
$145,000
$150,000
$155,000
$160,000
$165,000
$170,000
$175,000
$180,000
$185,000
$190,000
$195,000
$200,000
$205,000
$210,000
$215,000
$220,000
$225,000
$230,000
$235,000
$240,000
$245,000
$250,000
$260,000
$265,000
$270,000
$275,000
$280,000
$285,000
$290,000
$295,000
$300,000
$305,000
$310,000
$315,000
$320,000
$325,000
$330,000
$335,000
$340,000
$345,000
$350,000
$355,000
$360,000
$365,000
$370,000
$375,000
$380,000
$385,000
$390,000
$395,000
$400,000
$405,000
$410,000
$415,000
$420,000
$425,000
$430,000
$435,000
$440,000
$445,000
$450,000
$455,000
$460,000
$465,000
$470,000
$475,000
$480,000
$485,000
$490,000
$495,000
$500,000
$525,000
$550,000
$575,000
$600,000
$625,000
$650,000
$675,000
$700,000
$725,000
$750,000
$775,000
$800,000
$825,000
$850,000
$875,000
$900,000
$925,000
$950,000
$975,000
$1,000,000
$1,025,000
$1,050,000
$1,075,000
$1,100,000
$1,125,000
$1,150,000
$1,175,000
$1,200,000
$1,225,000
$1,250,000+
What is your current interest rate (if you know)
1.000%
1.125%
1.250%
1.375%
1.500%
1.625%
1.750%
1.875%
2.000%
2.125%
2.250%
2.375%
2.500%
2.625%
2.750%
2.875%
3.000%
3.125%
3.250%
3.375%
3.500%
3.625%
3.750%
3.875%
4.000%
4.125%
4.250%
4.375%
4.500%
4.625%
4.750%
4.875%
5.000%
5.125%
5.250%
5.375%
5.500%
5.625%
5.750%
5.875%
6.000%
6.125%
6.250%
6.375%
6.500%
6.625%
6.750%
6.875%
7.000%
7.125%
7.250%
7.375%
7.500%
7.625%
7.750%
7.875%
8.000%
8.125%
8.250%
8.375%
8.500%
8.625%
8.750%
8.875%
9.000%
9.125%
9.250%
9.375%
9.500%
9.625%
9.750%
9.875%
10.000%
10.125%
10.250%
10.375%
10.500%
10.625%
10.750%
10.875%
11.000%
11.125%
11.250%
11.375%
11.500%
11.625%
11.750%
11.875%
12.000%
12.125%
12.250%
12.375%
12.500%
12.625%
12.750%
12.875%
13.000%
13.125%
13.250%
13.375%
13.500%
13.625%
13.750%
13.875%
14.000%
14.125%
14.250%
14.375%
14.500%
14.625%
14.750%
14.875%
15.000%
15.125%
15.250%
15.375%
15.500%
15.625%
15.750%
15.875%
16.000%
16.125%
16.250%
16.375%
16.500%
16.625%
16.750%
16.875%
17.000%
17.125%
17.250%
17.375%
17.500%
17.625%
17.750%
17.875%
18.000%
18.125%
18.250%
18.375%
18.500%
18.625%
18.750%
18.875%
19.000%
How much are your monthly payments?
*
$
Can you now afford to start making regular payments again?
*
Yes
No
How many months are you behind?
*
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60+
How much do you owe on just the mortgage delinquency?
*
$
Do you want help to get it removed from your credit report.
Yes
No
Income Source
*
Employed W-2
Self Employed
Unemployed
Retirement Income / Social Security
Permanent Disability
Temporary Disability
Other
Other
Monthly Income before taxes
*
$
Have you filed any bankruptcy in the last 7 years?
*
Yes
No
Have you applied for loan modification already?
*
No
Yes
I don’t know
Were you denied for a loan mod?
Have you previously been approved for a loan mod?
*
No
Yes
I don’t know
When
Have you had a forbearance agreement?
*
Yes
No
I don’t know
When
Has a Sheriffs / Trustee Sale date been set?
*
No
Yes
Date
Is your property listed for sale?
*
Yes
No
Which solution is your first choice?
*
Loan Modification (permanent change in your payments)
Forbearance (temporary relief from payments)
Refinance (pay off your loan with a new one)
Sell Property
I don’t know
Other
Other
What hardship(s) lead to your missed payments?
*
Loss of employment or reduced income
Medical emergencies or illness
Divorce or separation
Death of a spouse or family member
Adjustable-rate mortgage reset
Unexpected major home repairs
Natural disasters
Excessive debt or high-interest loans
Inability to refinance or modify the loan
Relocation or job transfer
Other
Other
Questions/Comments
0
of 100 max words
Name
*
First Name
Your Last Name
*
Last Name
Property Street Address
*
Property Street Address
Property Street Address
Property Street Address
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State/Province
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*
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*
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