Mortgage Company

Please Select (AMC) Ameriquest Mortgage ABN AMRO Accredited Home Lenders Acqura Loan Services Aegis American General American Home Mortgage Ames Home Loans AmTrust (ASC) America’s Servicing Co. Aurora Avelo Bank of America Bank of the West Bank One Bayview BB&T Beneficial (HFC) Carrington Mortgage Cendant Cenlar Central Centex Central Mortgage Company Central Pacific Bank Champion Charter One Chase Home Finance Chase Manhattan CIT Group Citi Financial Citi Mortgage Citi-Residential/AMC Conseco Countrywide Deutsche Bank Dietech Dovenmuehle EMC Emigrant Mortgage Equifirst Equity One Everhome Mortgage Fairbanks Capital Fifth Third Bank First American First Capital First Franklin First Horizon First Merit Bank Flagstar Franklin Credit Freedom Mortgage Fremont Investment and Loan GMAC Greenpoint Greentree GRP Financial Homecomings HomEq Homeside Household Financial HSBC (Household) HUD Huntington Indymac Bank Irwin James B. Nutter & Company Key Bank LaSalle National Bank Lender Business Process Services Litton M&T Bank Midland Mortgage Lenders Nation Point Nation Star Mortgage National City / PNC Nationwide Advantage Net Bank New Century New Equity Mortgage North American NovaStar Ocwen Olympic Servicing One West Bank Option One PCFS/Provident PHFA PHH PNC Popular Mortgage Principal Residential Quantum RBMG Regions Mortgage Rural Housing Saxon Select Portfolio Selene Finance SN Servicing Specialized Loan Servicing Standard Federal Suntrust Mortgage Taylor Bean & Whitaker Third Federal TIB Tier One Union Planters Universal American Mortgage US Bank VA Vanderbilt Wachovia WAMU/Chase Weichert Financial Wells Fargo Wells Fargo Financial Wilshire World Savings Other

Monthly Mortgage Amount

Describe your mortgage payment history

Please Select Never Late Late 30 Days Late 60 Days Late 90 Days Late More Than 90 Days Received NOD Not Sure

Type of Loan

Please Select FHA VA Conventional Other

Do you have a second mortgage?
Yes No

What year did you buy your home?

Date of last payment made on-time
mm/dd/yy
Do you have a Foreclosure sale date?
Yes No
If Yes, what date?
mm/dd/yy
Do you have an Adjustable Rate Mortgage?
Yes No
Have you tried to Refinance your loan?
Yes No

Have you agreed to a workout program with your mortgage company in the last two years?
Yes No
What was the date?
mm/dd/yy
Are your taxes current?
Yes No
Second Mortgage Company

Second Mortgage Balance

Are you behind on payments?
Yes No
How far behind? 1 Payment 2 Payments 3 Payments 4 Payments or More

Can you afford your monthly payments?
Yes No
Is this a long-term issue?
Yes No
Have you considered selling your house?
Yes No
Would you like to receive a free case evaluation from our bankruptcy attorney?
Yes No

Have you ever filed for Bankruptcy?
Yes No
What was the date that you filed?

What type of bankruptcy did you file for? Please Select Chapter 13 Chapter 7 Other Don’t Know

Was the bankruptcy dismissed or discharged?
Yes No
Date dismissed or discharged

Additional Details on your Bankruptcy

First Name

Last Name

Email Address

Confirm Email

Street Address 1

Street Address 2

City

Zip

Daytime Phone

Evening Phone

Best Time to Call Please Select Morning Afternoon Evening Anytime

Addition Details or Comments