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Home Affordable Modification Program H ardship Affidavit

Borrower Name (first, middle, last): ___________________________________ Date of Birth: ________

Co-Borrower Name (first, middle, last): ________________________________ Date of Birth: ________

Property Street Address: ______________________________________________________________

Property City, ST, ZIP: ______________________________________________________________

Servicer:	______________________________________________________________
Loan Number:	______________________________________________________________

In order to qualify for _____________________________’s (“Servicer”) offer to enter into an

agreement to modify my loan under the federal government’s Home Affordable Modification Program (the “Agreement”), I/we am/are submitting this form to the Servicer and indicating by my/our checkmarks (“”) the one or more events that contribute to my/our difficulty making payments on my/our mortgage loan.

Borrower		Co-Borrower
Yes	No	Yes	No
			My income has been reduced or lost. For example: unemployment,
			underemployment, reduced job hours, reduced pay, or a decline in self-
			employed business earnings. I have provided details below under
			“Explanation.”
Yes	No	Yes	No
			My household financial circumstances have changed. For example: death
			in family, serious or chronic illness, permanent or short-term disability,
			increased family responsibilities (adoption or birth of a child, taking care of
			elderly relatives or other family members). I have provided details below
			under “Explanation.”
Yes	No	Yes	No
			My expenses have increased. For example: monthly mortgage payment
			has increased or will increase, high medical and health-care costs,
			uninsured losses (such as those due to fires or natural disasters),
			unexpectedly high utility bills, increased real property taxes. I have provided
			details below under “Explanation.”
Yes	No	Yes	No
			My cash reserves are insufficient to maintain the payment on my mortgage
			loan and cover basic living expenses at the same time. Cash reserves
			include assets such as cash, savings, money market funds, marketable
			stocks or bonds (excluding retirement accounts). Cash reserves do not
			include assets that serve as an emergency fund (generally equal to three
			times my monthly debt payments). I have provided details below under
			“Explanation.”
Yes	No	Yes	No
			My monthly debt payments are excessive, and I am overextended with my
			creditors. I may have used credit cards, home equity loans or other credit to
			make my monthly mortgage payments. I have provided details below under
			“Explanation.”
Yes	No	Yes	No
			There are other reasons I/we cannot make our mortgage payments. I have
			provided details below under “Explanation.”

Fannie Mae Form 1021

Page 1 of 4

April 2009

Information for Government Monitoring Purposes

The following information is requested by the federal government in order to monitor compliance with federal statutes that prohibit discrimination in housing. You are not required to furnish this information, but are encouraged to do so. The law provides that a lender or servicer may not discriminate either on the basis of this information, or on whether you choose to furnish it. If you furnish the information, please provide both ethnicity and race. For race, you may check more than one designation. If you do not furnish ethnicity, race, or sex, the lender or servicer is required to note the information on the basis of visual observation or surname if you have made this request for a loan modification in person. If you do not wish to furnish the information, please check

the box below.

BORROWER	I do not wish to furnish this information		CO-BORROWER	I do not wish to furnish this information

Ethnicity:	Hispanic or Latino		Ethnicity:	Hispanic or Latino
	Not Hispanic or Latino			Not Hispanic or Latino

Race:	American Indian or Alaska Native		Race:	American Indian or Alaska Native
	Asian			Asian
	Black or African American			Black or African American
	Native Hawaiian or Other Pacific Islander			Native Hawaiian or Other Pacific Islander
	White			White

Sex:	Female		Sex:	Female
	Male			Male

To be Completed by Interviewer		Interviewer’s Name (print or type)		Name/Address of Interviewer’s Employer

Face-to-face interview		Interviewer’s Signature	Date
Mail
Telephone		Interviewer’s Phone Number (include area code)
Internet

Borrower/Co-Borrower Acknowledgement

1.Under penalty of perjury, I/we certify that all of the information in this affidavit is truthful and the event(s) identified above has/have contributed to my/our need to modify the terms of my/our mortgage loan.

2.I/we understand and acknowledge the Servicer may investigate the accuracy of my/our statements, may require me/us to provide supporting documentation, and that knowingly submitting false information may violate Federal law.

3.I/we understand the Servicer will pull a current credit report on all borrowers obligated on the Note.

4.I/we understand that if I/we have intentionally defaulted on my/our existing mortgage, engaged in fraud or misrepresented any fact(s) in connection with this Hardship Affidavit, or if I/we do not provide all of the required documentation, the Servicer may cancel the Agreement and may pursue foreclosure on my/our home.

5.I/we certify that my/our property is owner-occupied and I/we have not received a condemnation notice.

6.I/we certify that I/we am/are willing to commit to credit counseling if it is determined that my/our financial hardship is related to excessive debt.

7.I/we certify that I/we am/are willing to provide all requested documents and to respond to all Servicer communication in a timely manner. I/we understand that time is of the essence.

Fannie Mae Form 1021

Page 2 of 4

April 2009

8.I/we understand that the Servicer will use this information to evaluate my/our eligibility for a loan modification or other workout, but the Servicer is not obligated to offer me/us assistance based solely on the representations in this affidavit.

9.I/we authorize and consent to Servicer disclosing to the U.S. Department of Treasury or other government agency, Fannie Mae and/or Freddie Mac any information provided by me/us or retained by Servicer in connection with the Home Affordable Modification Program.


_________________________ ___________			_________________________ ____________
Borrower Signature		Date	Co-Borrower Signature	Date
E-mail Address: _______________________			E-mail Address: ________________________
Cell Phone # _________________________			Cell Phone # __________________________
Home Phone #	_________________________		Home Phone #__________________________
Work Phone #	_________________________		Work Phone # __________________________
Social Security # ____ ___ ____			Social Security # ____ ___ ____

Explanation: ____________________________________________________________________________________

_______________________________________________________________________________________________

Fannie Mae Form 1021

Page 3 of 4

April 2009

_______________________________________________________________________________________________

Fannie Mae Form 1021

Page 4 of 4

April 2009

Question	Answer
Form Name	Fannie Mae Form 1021
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	fannie form 1021, fannie program hardship, mae form hardship, fannie mae appraisal form 1021

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