Request Mortgage Assistance Form – Fill Out and Use

If you are experiencing a financial hardship and need help, you must complete and submit this form along with other required documentation to be considered for foreclosure prevention options under the Making Home Affordable (MHA) Program. You must provide information about yourself and your intentions to either keep or transition out of your property; a description of the hardship that prevents you from paying your mortgage(s); information about all of your income, expenses and financial assets; whether you have declared bankruptcy; and information about the mortgage(s) on your principal residence and other single family real estate that you own. Finally, you will need to return to your loan servicer (1) this completed, signed and dated Request for Mortgage

Assistance (RMA); and (2) completed and signed IRS Form 4506-T or 4506T-EZ; and (3) all required income documentation identified in Section 4.

When you sign and date this form, you will make important certifications, representations and agreements, including certifying that all of

the information in this RMA is accurate and truthful.

SECTION 1: BORROWER INFORMATION

How many single family properties other than your principal residence do you and/or any co-borrower(s) own individually, jointly, or with others?

Has the mortgage on your principal residence ever had a Home Affordable Modification Program (HAMP) trial period plan or permanent modification?

Yes

No

Has the mortgage on any other property that you or any co-borrower own had a permanent HAMP modification?

Yes

No

If "Yes", how many?

Are you or any co-borrower currently in or being considered for a HAMP trial period plan on a property other than your principal residence?

Yes

No

SECTION 2: HARDSHIP AFFIDAVIT

I (We) am/are requesting review under MHA.

I am having difficulty making my monthly payment because of financial difficulties created by (check all that apply):

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

Other:

IIam unemployed and (a) I am receiving/will receive unemployment 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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SECTION 3: PRINCIPAL RESIDENCE INFORMATION

(This section is required even if you are not seeking mortgage assistance on your principal residence)

Yes

No

I am requesting mortgage assistance with my principal residence

If “yes”, I want to:

Keep the property

Sell the property

Property Address:

Loan I.D. Number:

Other mortgages or liens on the property?

Yes

No

Lien Holder / Servicer Name:

Loan I.D. Number:

Do you have condominium or homeowner association (HOA) fees?

Yes

No

If "Yes", Monthly Fee $

Are fees paid current?

Yes

No

Name and address that fees are paid to:

Does your mortgage payment include taxes and Insurance?

Yes

No

If "No", are the taxes and insurance paid current?

Yes

No

Annual Homeowner's Insurance

$

Is the property listed for sale?

Yes

No

If “Yes”, Listing Agent's Name:

Phone Number:

List date?

Have you received a purchase offer?

Yes

No

Amount of Offer

$

Closing Date:

Complete this section ONLY if you are requesting mortgage assistance with a property that is not your principal residence.

Principal residence servicer name:

Principal residence servicer phone number:

Is the mortgage on your principal residence paid?

Yes

No

if 'No", number of months your payment is past due (if known):

SECTION 4: COMBINED INCOME AND EXPENSE OF BORROWER AND CO-BORROWER

	Monthly Household Income		Monthly Household Expenses/Debt		Household Assets
			(*Principal Residence Expense Only)
	Monthly Gross wages	$	First Mortgage Principal &	$	Checking Account(s)	$
			Interest Payment*
	Overtime	$	Second Mortgage Principal &	$	Checking Account(s)	$
			Interest Payment*
	Self employment Income	$	Homeowner's Insurance*	$	Savings / Money Market	$
	Unemployment Income	$	Property Taxes*	$	CDs	$
	Untaxed Social Security / SSD	$	HOA/Condo Fees*	$	Stocks / Bonds	$
	Food Stamps/Welfare	$	Credit Cards/Installment debt	$	Other Cash on Hand	$
			(total min. payment)
	Taxable Social Security or	$		$
	retirement income		Child Support / Alimony
	Child Support / Alimony**	$	Car Payments	$
	Tips, commissions, bonus	$	Mortgage Payments other	$
	and overtime
			properties****
	Gross Rents Received ***	$	Other	$	Value of all Real Estate except	$
					principal residence
	Other	$			Other	$
	Total (Gross income)	$	Total Debt/Expenses	$	Total Assets	$

** Alimony, child support or separate maintenance income need not be disclosed if you do not choose to have it considered for repaying your mortgage debt.

*** Include rental income received from all properties you own EXCEPT a property for which you are seeking mortgage assistance in Section 6.

**** Include mortgage payments on all properties you own EXCEPT your principal residence and the property for which you are seeking mortgage assistance in Section 6.

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					Required Income Documentation
		(Your servicer may request additional documentation to complete your evaluation for MHA)
All Borrowers					Include a signed IRS Form 4506-T or 4506T-EZ
		Do you earn a wage?			For each borrower who is a salaried employee or hourly wage earner, provide the most recent pay stub(s) that reflects
					at least 30 days of year-to-date income.
		Borrower Hire Date (MM/DD/YY) _______________
		Co-borrower Hire Date (MM/DD/YY)_____________
		Are you self-employed?			Provide your most recent signed and dated quarterly or year-to date profit and loss statement.
		Do you receive tips, commissions, bonuses, housing			Describe the type of income, how frequently you receive the income and third party documentation describing the
		allowance or overtime?			income (e.g., employment contracts or printouts documenting tip income).
		Do you receive social security, disability, death			Provide documentation showing the amount and frequency of the benefits, such as letters, exhibits, disability policy or
		benefits, pension, public assistance or adoption			benefits statement from the provider and receipt of payment (such as two most recent bank statements or deposit
		assistance?			advices).
					Provide a copy of the divorce decree, separation agreement, or other written legal agreement filed with the court that
		Do you receive alimony, child support, or separation			states the amount of the payments and the period of time that you are entitled to receive them. AND
					Copies of your two most recent bank statements or deposit advices showing you have received payment.
		maintenance payments?
			Notice: Alimony, child support or separate maintenance income need not be disclosed if you do not choose to
			have it considered for repaying your mortgage debt.

Provide your most recent Federal Tax return with all schedules, including Schedule E.

	Do you have income from rental properties that are
	not your principal residence?		If rental income is not reported on Schedule E, provide a copy of the current lease agreement with bank statements
			showing deposit of rent checks.

SECTION 5: OTHER PROPERTIES OWNED

(You must provide information about all properties that you or the co-borrower own, other than your principal residence and any property described in

Section 6 below. Use additional sheets if necessary.)

Other Property #1

Property Address:						Loan I.D. Number:
Servicer Name:			Mortgage Balance $		Current Value	$
Property is:	Vacant	Second or seasonal home	Rented	Gross Monthly Rent $	Monthly mortgage payment* $

Other Property #2

Property Address:						Loan I.D. Number:
Servicer Name:			Mortgage Balance $		Current Value	$
Property is:	Vacant	Second or seasonal home	Rented	Gross Monthly Rent $	Monthly mortgage payment* $

Other Property #3

Property Address:						Loan I.D. Number:
Servicer Name:			Mortgage Balance $		Current Value	$
Property is:	Vacant	Second or seasonal home	Rented	Gross Monthly Rent $	Monthly mortgage payment* $

* The amount of the monthly payment made to your lender – including, if applicable, monthly principal, interest, real property taxes and insurance premiums..

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SECTION 6: OTHER PROPERTY FOR WHICH ASSISTANCE IS REQUESTED

(Complete this section ONLY if you are requesting mortgage assistance with a property that is not your principal residence.)

I am requesting mortgage assistance with a rental property .

Yes

No

Yes

No

I am requesting mortgage assistance with a second or seasonal home .

If “Yes” to either, I want to:

Keep the property

Sell the property

Property Address:

Loan I.D. Number:

Do you have a second mortgage on the property

Yes

No

If "Yes", Servicer Name:

Loan I.D. Number:

Do you have condominium or homeowner association (HOA) fees?

Yes

No If "Yes", Monthly Fee $

Are HOA fees paid current?

Yes

No

Name and address that fees are paid to:

Does your mortgage payment include taxes and insurance?

Yes

No

If "No", are the taxes and insurance paid current?

Yes

No

Annual Homeowner's Insurance $

Annual Property Taxes $

If requesting assistance with a rental property, property is currently:

Vacant and available for rent.

Occupied without rent by your legal dependent, parent or grandparent as their principal residence.

Occupied by a tenant as their principal residence.

Other __________________________________________________________________________

If rental property is occupied by a tenant: Term of lease / occupancy

____ / ____ / ____

-- ____ / ____ / ____

Gross Monthly Rent $

MM / DD / YYYY

MM / DD

/ YYYY

If rental property is vacant, describe efforts to rent property:

If applicable, describe relationship of and duration of non-rent paying occupant of rental property:

Is the property for sale?

Yes

No

If “Yes”, Listing Agent's Name:

Phone Number:

List date?

Have you received a purchase offer?

Yes

No

Amount of Offer $

Closing Date:

RENTAL PROPERTY CERTIFICATION

(You must complete this certification if you are requesting a mortgage modification with respect to a rental property.)

By checking this box and initialing below, I am requesting a mortgage modification under MHA with respect to the rental property described in this Section 6 and I hereby certify under penalty of perjury that each of the following statements is true and correct with respect to that property:

1.I intend to rent the property to a tenant or tenants for at least five years following the effective date of my mortgage modification. I understand that the servicer, the U.S. Department of the Treasury, or their respective agents may ask me to provide evidence of my intention to rent the property during such time. I further understand that such evidence must show that I used reasonable efforts to rent the property to a tenant or tenants on a year-round basis, if the property is or becomes vacant during such five-year period.

Note: The term “reasonable efforts” includes, without limitation, advertising the property for rent in local newspapers, websites or other commonly used forms of written or electronic media, and/or engaging a real estate or other professional to assist in renting the property, in either case, at or below market rent.

2.The property is not my secondary residence and I do not intend to use the property as a secondary residence for at least five years following the effective date of my mortgage modification. I understand that if I do use the property as a secondary residence during such five-year period, my use of the property may be considered to be inconsistent with the certifications I have made herein.

Note: The term “secondary residence” includes, without limitation, a second home, vacation home or other type of residence that I personally use or occupy on a part-time, seasonal or other basis.

3.I do not own more than five (5) single-family homes (i.e., one-to-four unit properties) (exclusive of my principal residence).

Notwithstanding the foregoing certifications, I may at any time sell the property, occupy it as my principal residence, or permit my legal dependent, parent or grandparent to occupy it as their principal residence with no rent charged or collected, none of which will be considered to be inconsistent with the certifications made herein.

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

Initials: Borrower ________

Co-borrower _______

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SECTION 7: 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 respective 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 this RMA is received by your servicer.

SECTION 8: 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

American Indian or Alaska Native

Race:

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

Female

Sex:

Male

Male

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SECTION 9: BORROWER AND CO-BORROWER ACKNOWLEDGEMENT AND AGREEMENT

1.I certify that all of the information in this RMA is truthful and the hardship(s) identified above has contributed to submission of this request for mortgage relief.

2.I understand and acknowledge that the Servicer, the U.S. Department of the Treasury, the owner or guarantor of my mortgage loan, or their respective agents may investigate the accuracy of my statements, may require me to provide additional supporting documentation and that knowingly submitting false information may violate Federal and other applicable law.

3.I authorize and give permission to the Servicer, the U.S. Department of the Treasury, and their respective agents, to assemble and use a current consumer report on all borrowers obligated on the loan, to investigate each borrower’s eligibility for MHA and the accuracy of my statements and any documentation that I provide in connection with my request for assistance. I understand that these consumer reports may include, without limitation, a credit report, and be assembled and used at any point during the application process to assess each borrower’s eligibility thereafter.

4.I understand that if I have intentionally defaulted on my existing mortgage, engaged in fraud or if it is determined that any of my statements or any information contained in the documentation that I provide are materially false and that I was ineligible for assistance under MHA, the Servicer, the U.S. Department of the Treasury, or their respective agents may terminate my participation in MHA, including any right to future benefits and incentives that otherwise would have been available under the program, and also may seek other remedies available at law and in equity, such as recouping any benefits or incentives previously received.

5.I certify that any property for which I am requesting assistance is a habitable residential property that is not subject to a condemnation notice.

6.I certify that I am willing to provide all requested documents and to respond to all Servicer communications in a timely manner. I understand that time is of the essence.

7.I understand that the Servicer will use the information I provide to evaluate my eligibility for available relief options and foreclosure alternatives, but the Servicer is not obligated to offer me assistance based solely on the representations in this document or other documentation submitted in connection with my request.

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

9.If I am eligible for assistance under MHA, and I accept and agree to all terms of an MHA notice, plan, or agreement, I also agree that the terms of this Acknowledgment and Agreement are incorporated into such notice, plan, or agreement by reference as if set forth therein in full. My first timely payment, if required, following my servicer's determination and notification of my eligibility or prequalification for MHA assistance will serve as my acceptance of the terms set forth in the notice, plan, or agreement sent to me.

10.I understand that my Servicer will collect and record personal information that I submit in this RMA and during the evaluation process, including, but not limited to, my name, address, telephone number, social security number, credit score, income, payment history, government monitoring information, and information about my account balances and activity. I understand and consent to the Servicer’s disclosure of my personal information and the terms of any MHA notice, plan or agreement to the U.S. Department of the Treasury and its agents, Fannie Mae and Freddie Mac in connection with their responsibilities under MHA, companies that perform support services in conjunction with MHA, any investor, insurer, guarantor, or servicer that owns, insures, guarantees, or services my first lien or subordinate lien (if applicable) mortgage loan(s) and to any HUD-certified housing counselor.

11.I consent to being contacted concerning this request for mortgage assistance at any e-mail address or cellular or mobile telephone number I have provided to the Servicer. This includes text messages and telephone calls to my cellular or mobile telephone.

The undersigned certifies 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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HOMEOWNER'S HOTLINE

If you have questions about this document or the Making Home Affordable Program, please call your servicer.

If you have questions about the program that your servicer cannot answer or need further counseling, you can call the

Homeowner's HOPE™ Hotline at 1-888-995-HOPE (4673).

The Hotline can help with questions about the program and offers free HUD-certified counseling services in English and Spanish.

NOTICE TO BORROWERS

Return your completed, signed and dated form to your mortgage servicer/company. If you're unsure of where to send the form, visit the Making Home Affordable website, www.makinghomeaffordable.gov. Find your mortgage company information by clicking: Get Answers >> Contact My Mortgage Company.

Be advised that by signing this document you understand that any documents and information you submit to your servicer in connection with the Making Home Affordable Program are under penalty of perjury. Any misstatement of material fact made in the completion of these documents including but not limited to misstatement regarding your occupancy of your property, hardship circumstances, and/or income, expenses, or assets will subject you to potential criminal investigation and prosecution for the following crimes: perjury, false statements, mail fraud, and wire fraud. The information contained in these documents is subject to examination and verification. Any potential misrepresentation will be referred to the appropriate law enforcement authority for investigation and prosecution. By signing this document you certify, represent and agree that: “Under penalty of perjury, all documents and information I have provided to my Servicer in connection with the Making Home Affordable Program, including the documents and information regarding my eligibility for the program, are true and correct.”

If you are aware of fraud, waste, abuse, mismanagement or misrepresentations affiliated with the Troubled Asset Relief Program, please contact the SIGTARP Hotline by calling 1-877-SIG-2009 (toll-free), or www.sigtarp.gov and provide them with your name, our name as your servicer, your property address, loan number and the reason for escalation.

Beware of Foreclosure Rescue Scams. Help is FREE!

•There is never a fee to get assistance or information about the Making Home Affordable Program from your lender or a HUD-approved housing counselor.

•Beware of any person or organization that asks you to pay a fee in exchange for housing counseling services or modification of a delinquent loan.

•Beware of anyone who says they can “save” your home if you sign or transfer over the deed to your house. Do not sign over the deed to your property to any organization or individual unless you are working directly with your mortgage company to forgive your debt.

•Never make your mortgage payments to anyone other than your mortgage company without their approval.

•If you think you've been scammed, visit www.makinghomeaffordable.gov. Click on Get Answers >> Avoid Scams/File a Complaint.

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