Mortgage Assistance Form – Fill Out and Use This PDF

Making Home Afordable Program

Request For Mortgage Assistance (RMA)

REQOR MORTGAGE ASSISTANCE (RMA) page 1	COMPLETE ALL FOAGES OF THIS FORM
Loan I.D. Number____________________________________________	Servicer ____________________________________________________

I want to:	Keep the Property	Sell the Property
The property is my:	Primary Residence	Second Home	Investment Property
The property is:	Owner Occupied	Renter Occupied for Less than 12 Months	Vacant for Less than 12 Months

Mailing address

Property address (if same as mailing address, just write same)

E-mail address

Is the property listed for sale?

Yes

No

Have you contacted a credit-counseling agency for help

Yes

No

Have you received an ofer on the property?

Yes

No

If yes, please complete the following:

Date of ofer _________ Amount of ofer $_____________________

Counselors Name: _________________________________________

Agents Name: ___________________________________________

Agency Name: ____________________________________________

Agents Phone Number: ____________________________________

Counselors Phone Number: __________________________________

For Sale by Owner?

Yes

No

Counselors E-mail: ________________________________________

Who pays the real estate tax bill on your property?

Who pays the hazard insurance premium for your property?

I do

Lender does

Paid by condo or HOA

I do

Lender does

Paid by Condo or HOA

Are the taxes current?

Yes

No

Is the policy current?

Yes

No

Condominium or HOA Fees

Yes

No

$ __________________

Name of Insurance Co.: ______________________________________

Paid to: _________________________________________________

Insurance Co. Tel #: _________________________________________

Have you iled for bankruptcy?	Yes	No	If yes:	Chapter 7	Chapter 13	Filing Date:_________________________
Has your bankruptcy been discharged?		Yes	No	Bankruptcy case number _________________________________

Additional Liens/Mortgages or Judgments on this property:

HARDSHIP AFFIDAVIT

I (We) am/are requesting review under the Making Home Afordable Program.

I am having diiculty making my monthly payment because of inancial diiculties created by (check all that apply):

My household income has been reduced. For example: reduced pay	My monthly debt payments are excessive and I am overextended with
or hours, decline in business earnings, death, disability or divorce of a	my creditors. Debt includes credit cards, home equity or other debt.
borrower or co-borrower.
My expenses have increased. For example: monthly mortgage payment	My cash reserves, including all liquid assets, are insufficient to maintain
reset, high medical or health care costs, uninsured losses, increased	my current mortgage payment and cover basic living expenses at the
utilities or property taxes.	same time.
I am unemployed and (a) I am receiving/will receive unemployment	Other:
benefits or (b) my unemployment benefits ended less than 6 months ago.

Explanation (continue on a separate sheet of paper if necessary): __________________________________________________________________

______________________________________________________________________________________________________________________

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REQUEST FOR MORTGAGE ASSISTANCE (RMA) PAGE 2COMPLETE ALL FOUR PAGES OF THIS FORM

INCOME/EXPENSES FOR HOUSEHOLD1								Number of People in Household:
Monthly Household Income				Monthly Household Expenses/Debt				Household Assets
Monthly Gross Wages		$		First Mortgage Payment		$		Checking Account(s)		$
Overtime		$		Second Mortgage Payment		$		Checking Account(s)		$
Child Support/Alimony/		$		Insurance		$		Savings/Money Market		$
Separation2
Social Security/SSDI		$		Property Taxes		$		CDs		$
Other monthly income from		$		Credit Cards/Installment		$		Stocks/Bonds		$
pensions, annuities or				Loan(s) (total minimum
retirement plans				payment per month)
Tips, commissions, bonus		$		Alimony, child support		$		Other Cash on Hand		$
and self-employed income				payments
Rents Received		$		Net Rental Expenses		$		Other Real Estate		$
								(estimated value)
Unemployment Income		$		HOA/Condo Fees/Property		$		Other _____________		$
				Maintenance
Food Stamps/Welfare		$		Car Payments		$		Other _____________		$
Other (investment income,		$		Other ________________		$		Do not include the value of life insurance or
royalties, interest, dividends				_____________________				retirement plans when calculating assets (401k,
etc.)								pension funds, annuities, IRAs, Keogh plans, etc.)
Total (Gross Income)		$		Total Debt/Expenses		$		Total Assets		$

INCOME MUST BE DOCUMENTED

1Include combined income and expenses from the borrower and co-borrower (if any). If you include income and expenses from a household

member who is not a borrower, please specify using the back of this form if necessary.

2You are not required to disclose Child Support, Alimony or Separation Maintenance income, unless you choose to have it considered by your servicer.

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			Name/Address of Interviewer’s Employer
This request was taken by:			Interviewer’s Name (print or type) & ID Number
Face-to-face interview
			Interviewer’s Signature	Date
Mail
Telephone
			Interviewer’s Phone Number (include area code)
Internet

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REQUEST FOR MORTGAGE ASSISTANCE (RMA) PAGE 3

COMPLETE ALL FOUR PAGES OF THIS FORM

DODD-FRANK CERTIFICATION

The following information is requested by the federal government in accordance with the Dodd-Frank Wall Street Reform and Consumer Protection Act (Pub. L. 111-203). You are required to furnish this information. The law provides that no person shall be eligible to begin receiving assistance from the Making Home Affordable Program, authorized under the Emergency Economic Stabilization Act of 2008 (12 U.S.C. 5201 et seq.), or any other mortgage assistance program authorized or funded by that Act, if such person, in connection with a mortgage or real estate transaction, has been convicted, within the last 10 years, of any one of the following: (A) felony larceny, theft, fraud, or forgery, (B) money laundering or (C) tax evasion.

I/we certify under penalty of perjury that I/we have not been convicted within the last 10 years of any one of the following in connection with a mortgage or real estate transaction:

(a)felony larceny, theft, fraud, or forgery,

(b)money laundering or

(c)tax evasion.

I/we understand that the servicer, the U.S. Department of the Treasury, or their agents may investigate the accuracy of my statements by performing routine background checks, including automated searches of federal, state and county databases, to confirm that I/we have not been convicted of such crimes. I/we also understand that knowingly submitting false information may violate Federal law.

This certification is effective on the earlier of the date listed below or the date received by your servicer.

ACKNOWLEDGEMENT AND AGREEMENT

In making this request for consideration under the Making Home Afordable Program, I certify under penalty of perjury:

1.That all of the information in this document is truthful and the event(s) identified on page 1 is/are the reason that I need to request a modification or forbearance of the terms of my mortgage loan, short sale or deed-in-lieu of foreclosure.

2.I understand that the Servicer, the U.S. Department of the Treasury, or their agents may investigate the accuracy of my statements, and may require me to provide supporting documentation. I also understand that knowingly submitting false information may violate Federal law.

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

4.I understand that if I have intentionally defaulted on my existing mortgage, engaged in fraud or misrepresented any fact(s) in connection with this document, the Servicer may cancel any Agreement under Making Home Affordable and may pursue foreclosure on my home.

5.That I have not received a condemnation notice, there has been no change in the ownership of the Property since I signed the documents for the mortgage that I want to modify, and:

(a)for consideration for the Home Affordable Modification Program (HAMP) or unemployment assistance, my property is owner-occupied and I intend to reside in this property for the next twelve months, or

(b)for consideration for the Home Affordable Foreclosure Alternatives Program (HAFA), my property has been owner-occupied within the last twelve months.

6.I am willing to provide all requested documents and to respond to all Servicer questions in a timely manner.

7.I understand that the Servicer will use the information in this document to evaluate my eligibility for a loan modification

or forbearance or short sale or deed-in-lieu of foreclosure, but the Servicer is not obligated to offer me assistance based solely on the statements in this document.

8.I am willing to commit to credit counseling if it is determined that my financial hardship is related to excessive debt.

9.I understand that the Servicer will collect and record personal information, including, but not limited to, my name, address, telephone number, Social Security Number, credit score, income, payment history, government monitoring information, and information about account balances and activity. I understand and consent to the disclosure of my personal information and the terms of any Making Home Affordable Agreement by Servicer to (a) the U.S. Department of the Treasury, (b) Fannie Mae and Freddie Mac in connection with their responsibilities under the Homeowner Affordability and Stability Plan; (c) any investor, insurer, guarantor or servicer that owns, insures, guarantees or services my first lien or subordinate lien (if applicable) mortgage loan(s); (d) companies that perform support services in conjunction with Making Home Affordable; and (e) any HUD-certified housing counselor.

The undersigned certifies/y under penalty of perjury that all statements in this document are true and correct.

Borrower Signature

Social Security Number

Date of Birth

Date

Co-borrower Signature

Social Security Number

Date of Birth

Date

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