Request Mortgage Assistance Form – Fill Out and Use This PDF

A Customer is someone who is obligated on the Note for the loan or interested in assuming responsibility for the Note. If another person not on the Note has community property or similar rights per applicable state law, please provide their name.

Fill in the Customer's name, the last four digits of the Social Security number, the date of birth, the mobile or daytime number with area code, the preferred contact method (Text, Voice or Email) and the email address, for the Customer and for the Additional Customer.

Under the Hardship Affidavit, enter what caused you to be unable to make your Contractual payment.

Enter the approximate date the hardship causing mortgage payment challenges began, then mark Resolved as of (date), Short Term (hardship is expected to be resolved in the next 6 months) or Long Term (hardship is expected to be permanent or resolved in greater than 6 months).

Check all boxes that explain your situation and send the documents that apply. For Unemployment, send a copy of your benefits statement or letter detailing the amount, frequency and duration of your unemployment benefits.

For Income reduction/underemployment or Payment increase, no hardship documentation is required as long as you have submitted documents that show your income.

For Divorce or legal separation: a divorce decree or separation agreement signed by the court; or a current credit report showing divorce, separation or different address of non-occupying customer; or a recorded quitclaim deed showing that the non-occupying customer or additional customer has relinquished all rights to the property.

For the death of a customer, or death of either the primary or additional wage earner in the household or a dependent family member: a death certificate; or an obituary or newspaper article reporting the death.

For long-term or permanent disability or serious illness of a customer, additional customer or a dependent family member, do not send medical records or any details of your illness or disability. Instead, please send: a written statement from you or other documentation verifying disability or illness; or proof of monthly insurance benefits or government assistance (with expiration date, if applicable).

For a disaster (natural or man-made) adversely affecting the property or customer's place of employment: an insurance claim; or proof of a FEMA grant or Small Business Administration loan; or evidence that customer or employer property is in a federally-declared disaster area.

Mark All assistance options I'm interested in, or Only options that involve moving out of the property.

Additional contributor information is optional. Does anyone not listed on the loan live in and contribute financially to the household? Mark Yes or No, then enter the monthly amount they contribute to the household (including amount contributed to the mortgage).

Enter the first and last name(s) and the last four digits of the SSN of the contributor, and indicate any living expenses for this person(s) in the Contributor column of the Monthly Living Expenses section of this form.

For each additional contributor on the property, complete an Authorization to Obtain Consumer Credit Report form, which you'll find in the Forms Center at chase.com/MortgageAssistance, and provide proof of the contributor's income.

Under Monthly household income, enter wages for Customer, Co-Customer and Contributor, with the employer name and start date for Employer 1 and Employer 2. If you work seasonally or in the education field, enter how many months per year you are paid.

For self-employment income (includes 1099 income), enter the percentage of business ownership. For benefits income (Social Security benefits, investments, pensions or other retirement benefits), specify the benefits.

Voluntary income is child support, alimony or separation maintenance. You aren't required to disclose child support, alimony or separation maintenance income unless you want Chase to consider it as qualifying income.

Also enter gross rents or boarder rents received (Primary recipient), unemployment income with its start date and end date, food stamps or welfare (Primary recipient), tips, commissions, bonuses and other income, then the total monthly income.

Under Monthly living expenses, Food, Utilities and Automobile (insurance, maintenance, gas) are required fields for Customer(s) and Contributor(s). If there is no automobile, check No automobile.

Also enter life insurance premium, clothing, cable, internet and phone, medical, tuition or school, child care (daycare, babysitting) and child support or alimony, then the total monthly living expenses.

Under Household assets, provide the most recent statement for each account listed. Do you have any existing asset accounts as listed under Household assets? Mark Yes or No. If Yes, complete this section excluding Retirement Funds.

Under Step 4: Property Information, enter the property address, the number of people in household and the number of vehicles. The property is my: mark Primary Residence, Second Home or Investment. The property is: mark Owner Occupied, Renter Occupied or Vacant.

If any customer or occupant of the property is a military Servicemember who is currently on Active Duty or has been on Active Duty within the last 12 months, or is a dependent of a Servicemember, call Chase Military Services at 1-877-469-0110.

List any other mortgages or liens associated with this property, with the servicer and the account number. If you have more than one loan with Chase, complete a Request for Mortgage Assistance form for each account you'd like Chase to review for assistance.

Condominium or HOA fees? Mark Yes or No. If yes, enter how much each month. Are payments up to date? Mark Yes or No.

If you own other properties, fill out the Other Properties Owned section. Customers with more than two additional properties download the Schedule of Real Estate Owned form from the Forms Center at chase.com/MortgageAssistance and include the completed form with this application.

Third-party authorization is optional. If you want, you can authorize someone to work with Chase on your behalf by entering the name of the third party, the phone number and the address.

FHA Customer(s) Only: enter the reduction in income or the hardship(s) that will prevent you from making the next required Mortgage Payment due on ____________ during the month that it is due.

Step 5: Please read carefully and sign. In making this request for consideration, I certify under penalty of perjury that I understand and agree that: all the information in this document is true, and the hardships listed in Step 2 explain why I'm requesting mortgage assistance.

Anyone who knowingly submits a false claim or makes a false statement is subject to criminal and/or civil penalties, including confinement for up to five years, fines, and civil and administrative penalties (18 U.S.C. §§ 287, 1001, 1010, 1012, 1014; 31 U.S.C. §§ 3729, 3802). By signing this document, you certify that all the information is truthful.

When Chase receives this form and all required documents, Chase will assign a team of dedicated specialists to your loan who will call you within five business days to talk about your next steps.

Send your information by Regular Mail to Chase PO Box 469030 Glendale, CO 80246-9030, by Overnight Mail to Chase 720 S. Colorado Blvd., STE 210 Glendale, CO 80246-1904, by Fax at 1-866-282-5682, or online at chase.com. After you have submitted your documentation, call 1-877-496-3138 to let Chase know.