Form Preview Example

Checklist

We need the following documents in order to expedite your modification review:

All Borrowers:

A completed, signed, and dated Borrower Assistance Application from all obligated parties Most recent one (1) full month of paystubs; minimum of two consecutive paystubs for new employment

Most recent bank statement from all accounts, with all pages, for each borrower

Signed and dated federal tax return(s), with all schedules, for the most recent calendar year (If not required to file taxes, provide a signed and dated letter of explanation)

If applicable, most recent HOA statement to verify monthly Homeowners’ Association Dues Completed, signed, and dated IRS Form 4506T or 4506T-EZ

Non-Borrowers

If a non-borrower(s) contributes money towards the mortgage payment and/or household expenses:

Signed and dated letter from non-borrower(s) stating monthly contribution amount A letter of authorization to obtain a credit report on all contributing non-borrowers Proof of income to support contribution amount; see borrower income requirements Most recent bank statement, with all pages, for each contributing non-borrower

Additional documents for other sources of income:

If you are Self-Employed:

Signed and dated tax return(s), with all schedules and forms, for the most recent calendar year (1040s, and if Corporation or LLC, include 1120s, K-1s, and/or 1065s)

Last three (3) months or most recent quarterly, signed and dated, Profit and Loss Statement Last three (3) months business bank statements for the same period reflected on the Profit and Loss Statement

If you own rental properties:

Copy of all fully executed lease agreements

Most recent bank statement, with all pages, to verify rental income deposits (if unable to provide bank statements, please provide cancelled checks or Schedule E of recent tax return) Recent mortgage or payoff statements for all rental properties owned; if loans are not escrowed, provide property tax statement, homeowner’s insurance declaration page, and HOA statement, if applicable

Revised: 09/07/2018

If you receive Fixed Income (e.g. SSI, pension, long term disability, alimony, child support)

Award letter or benefit statement showing the amount, frequency, and duration of pay Most recent bank statement, with all pages, to verify deposits

If you receive Variable Income (e.g. seasonal income, school employees):

Evidence of the frequency and duration of pay, and documentation to support income received (e.g. Employment Contract, Letter of Explanation from Employer, along with paystubs and/or bank statements for the months worked)

In cases where a divorce or legal separation has occurred:

A copy of a divorce decree or legal separation filed/acknowledged with the Court A copy of a recorded Quit Claim Deed or Warranty Deed filed with the County

If your loan is not currently escrowed for property tax and/or hazard insurance:

A copy of the most recent property tax statement and/or hazard insurance declaration page

If you are reapplying due to a change in your circumstances:

A signed and dated letter of explanation and supporting documentation to outline your change in circumstance.

*Note: Any expenses disclosed must be validated with supporting documents (e.g. Alimony, Child Support, Liens, and Judgments)

If you have any questions or concerns regarding this checklist, please contact our office toll free at

1-888-504-7300, Monday through Thursday from 6:00am to 7:00pm, and Friday from 6:00am to 6:00pm Pacific Time.

Revised: 09/07/2018

This completed Borrower Assistance Application and all required documentation must be sent to one of the following locations:

Mail: Attn: Loss Mitigation

Rushmore Loan Management Services LLC

15480 Laguna Canyon Road

Irvine, CA 92618

Secure Fax: 949-341-2238

Questions: Call us at 888-504-7300 M-Th 6:00 am PST to 7:00 pm PST or

F 6:00 am PST to 6:00 PST.

BORROWER ASSISTANCE APPLICATION

If you are experiencing a temporary or long-term hardship and need help, you must complete and submit this application along with other required documentation to be considered for available

options. You must disclose information about (1) your intentions to either keep or transition out of the property; (2) the property’s status; (3) bankruptcy; and (4) your credit counseling agency or

representative, if any.

You must disclose information about your income, expenses and assets. This application also lists the required income documentation that you must submit in support of your request for assistance. You must also complete the Hardship Affidavit in which you disclose the nature of your hardship. The Hardship Affidavit informs you of the required documentation that you must submit in support of your hardship claim.

When you sign and date this application you will make certain certifications, representations and agreements, including certifying that the information you provide in the application is accurate and truthful and that the identified hardship has contributed to your need for mortgage relief.

This application requires a completed and signed IRS Form 4506-T, the required income documentation, the required hardship documentation, a signed and completed Dodd-Frank Certification and, if applicable, a completed and signed Non-Borrower Contribution form

Loan Number: ______________________ (found on your monthly mortgage statement)

I want to:	Keep the property		Vacate the property			Sell the property		Undecided
If you wish to keep the property, for how long? ______________________
The property is currently:		My primary residence			A second home
		An investment property
The property is currently:		Owner occupied		Renter occupied			Vacant
				1

CONTACT INFORMATION

Borrower	Co-Borrower

Borrower Name: _____________________	Co-Borrower Name: __________________

SSN _______________ DOB __________	SSN _____________	DOB __________

Home Phone # ( )	Home Phone # ( )
Best time to call:	Best time to call:

Cell/Mobile Phone # ( )	Cell/Mobile Phone # (	)
Best time to call:	Best time to call:

Email: ____________________________	Email: ____________________________

My primary language is Spanish. This information will be used to assign you a Spanish-speaking representative when available after your application is received. Mi lengua principal es el español. Esta información sera utilizada para asignar un representante que hable español cuando este disponsible después que su aplicación ha sido recibida. Llámenos al teléfono indicado si necesita ayuda para completar esta aplicación.

Mailing Address: _________________________________________________________

Property Address (if the same as mailing address, just write “same”)


Have you contacted a credit counseling agency? Yes		No
If “Yes”, provide counselor contact information:
Agency Name: _________________	Counselor Name: ___________________
	Counselor Phone #: _________________
	Counselor email: ____________________

Rushmore may contact this agency about my Loan. Yes No

Do you have a lawyer or other representative we should contact about this application? Yes No

If “Yes”, provide contact information:

Law Firm Name (if any): _________________ Representative Name: _____________

Phone #: _______________________

Email: _________________________

Rushmore should only contact this representative about my Loan.	Yes	No

2

PROPERTY INFORMATION

Estimated Market Value of the property: $ _________________________________

Is the property listed for sale?		Yes	No	If “Yes”, what was the listing date? _____________

Have you received an offer on the property?				Yes	No
Date of Offer: _____________				Amount of Offer: $ ______________
Agent’s Name: _____________				Agent’s phone #: ______________
For Sale by Owner	Yes	No

Do you have condominium or homeowner association (HOA) fees?						Yes	No
Total monthly amount: $ ______________

Name and Address that fees are paid to: ________________________________________

______________________________________________________________________

Who pays the real estate tax bill on the property?				I/We do		Servicer does
Are the taxes current?	Yes	No

Who pays the homeowners insurance policy on the property?					I/We do		Servicer does
Is the policy current?	Yes	No	Name of Insurance Company: _________________
			Insurance Company Phone #: _________________

Are there any liens/other mortgages or judgments on the property?						Yes	No
If “Yes”, provide :
Lien holder/Servicer name: ___________________				Phone #: ________________
Balance Amount: $ ________________			Monthly payment amount: $ ________________
Lien holder/Servicer name: ___________________				Phone #: ________________
Balance Amount: $ ________________			Monthly payment amount: $ ________________
Lien holder/Servicer name: ___________________				Phone #: ________________
Balance Amount: $ ________________			Monthly payment amount: $ ________________

MORTGAGE INFORMATION

Has the mortgage on your property 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

	3

BORROWER INFORMATION


Have you or the co-borrower filed bankruptcy?			Yes		No
Chapter 7	Chapter 11			Chapter 12			Chapter 13
Has the bankruptcy been discharged?		Yes	No	Bankruptcy Case No. :
Has/Was the mortgage on the property been reaffirmed?					Yes	No	Don’t know

If you have or will receive a discharge from a bankruptcy and the mortgage was not reaffirmed in the case, we will only exercise our rights against the property and are not attempting any act to collect the discharged debt from you personally. Your decision to discuss workout options with us is strictly voluntary. You are not obligated to pursue any workout option discussed with us. At your request, we will immediately terminate any such discussions should you no longer wish to purse these options to retain your property.

SERVICE MEMBERS

Is any borrower an active duty service member? Yes No

If “Yes”, has any borrower been deployed away from his/her primary residence or received a

permanent Change of Station order?

Yes

Is any borrower the surviving spouse of a deceased service member who was on active duty at the

time of death? Yes

EMPLOYMENT INFORMATION

Borrower

Company Name: ______________________________ Start Date: ________________

Job Title: _______________________

Co-Borrower

Company Name: ______________________________ Start Date: ________________

Job Title: _______________________

OTHER PROPERTY FOR WHICH ASSISTANCE IS REQUESTED

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

I am requesting mortgage assistance with a rental property that is not your principal residence:

Yes	No
I am requesting mortgage assistance with a second or seasonal home:				Yes	No
If “Yes” to either, I want to:		Keep the property	Sell the property

Property Address: _____________________________________________ Loan Number: __________

Do you have a second mortgage on the property?	Yes	No
If “Yes”: Servicer Name: __________________________________________
Loan Number: __________
Do you have condo or Homeowner’s association (HOA) fee?		Yes	No
If “Yes”: Monthly Fee: _______________ Are HOA fees current?			Yes	No

Name and address fees are paid to: ____________________________________________

Does your mortgage payment include taxes and insurance?		Yes	No
If “NO”: Are taxes and insurance paid and current?	Yes	No

Annual Homeowner’s Insurance: ____________________ Annual Property Taxes: ___________________

Vacant and available for rent

Occupied by a tenant as their principal residence

Other: _______________________________________________________

If rental property is occupied by a tenant:

Term/Lease of Occupancy (MM/DD/YYYY - MMMM/DD/YYYY): ______________________________

Gross Monthly Rent: $ ________________________________

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

______________________________________________________________________________________________

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

Is the property for sale?	Yes No
If “Yes”, Listing Agent Name: ____________________________________________
Listing Agent Phone #: _________________________________________________
Listing Date: ___________________________ Have you received purchase offer? Yes		No

Amount of Offer: $ _________________________________________ Closing Date:_________________

RENTAL PROPERTY CERTIFICATION

You must complete this certification if you are requesting mortgage assistance 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 and I hereby certify under penalty of perjury that each of the following statements is true and correct with respect to that property:

1.1 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 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 newspaper, 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 intent 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 primary residence.

Notwithstanding the 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 certificate is effective on the earlier of the date listed below or the date the RMA is received by you servicer.

Initials: _______	_______________________	____________
	Borrower	Date
Initials: _______	_______________________	____________
	Co-Borrower	Date
	6

	FINANCIAL INFORMATION

Borrower Monthly Income		Borrower Assets
Gross Wages	$	Checking Account	$

Overtime	$	Checking Account	$

Child support/Alimony*	$	Savings/Money Market	$
Non-Taxable Social Security/SSDI	$	Stocks/Bonds/CDs	$

Taxable SS Benefits or Other		Expected Assets (e.g., inheritance,
Monthly Income (e.g., Annuities	$	Expected Assets (e.g., inheritance,	$
or Retirement Plans, etc.)		tax, returns, etc.)
or Retirement Plans, etc.)

Tips, Commissions, Bonus and	$	Total Amount in Additional	$
Self-employment income	$	Assets (e.g. trusts)	$
Self-employment income		Assets (e.g. trusts)
Rents Received	$	Other Real Estate Owned	$
Rents Received	$	(estimated value)	$
		(estimated value)

Unemployment Income	$	Retirement	$

Food stamps/Welfare	$	Other Cash on Hand	$
Other	$	Other	$
Co-Borrower Monthly Income		Co-Borrower Assets
Gross Wages	$	Checking Account	$
Overtime	$	Checking Account	$

Child support/Alimony*	$	Savings/Money Market	$

Non-Taxable Social Security/SSDI	$	Stocks/Bonds/CDs	$
Taxable SS Benefits or Other		Expected assets (e.g., inheritance,
Monthly Income (e.g., Annuities	$	Expected assets (e.g., inheritance,	$
or Retirement Plans, etc.)		tax, returns, etc.)
or Retirement Plans, etc.)

Tips, Commissions, Bonus and	$	Total Amount in Additional	$
Self-Employment Income	$	Assets (e.g. trusts)	$
Self-Employment Income		Assets (e.g. trusts)

Rents Received	$	Other Real Estate Owned	$
Rents Received	$	(estimated value)	$
		(estimated value)
Unemployment Income	$	Retirement	$

Food Stamps/Welfare	$	Other Cash on Hand	$

Other	$	Other	$

*Child Support, alimony, separation maintenance need not be disclosed if you do not want it considered in support of your Loan payments.

Monthly Household Expenses

First Mortgage	$	Electric	$

Second Mortgage	$	Gas	$
Homeowner’s Insurance*	$	Trash	$
Property Taxes	$	Cable	$

HOA/Condo Fees/Property	$	Cell phone	$
Maintenance	$	Cell phone	$
Maintenance
Student Loan (if not deferred)	$	Food	$
Car Payment	$	Clothing	$

Credit Cards/Other Installment		Out of Pocket Medical/Dental
Loans (minimum monthly	$	Out of Pocket Medical/Dental	$
Loans (minimum monthly	$	Expenses	$
payment)		Expenses
payment)
Car Expense/Gas	$	Life Insurance	$
Alimony/Child Support Payments	$	Mortgage Payments on Other	$
Alimony/Child Support Payments	$	Properties	$
		Properties

Other	$	Other	$

If you want Rushmore to consider Non-Borrower/Contributor Income (a person who resides in the property or contributes to household income but is not a listed Borrower on the Loan), please submit a completed and signed Non-Borrower Contribution form with this application.

REQUIRED INCOME DOCUMENTATION

Please refer to the Checklist included in this package

Any income documentation that you submit as part of your Borrower Assistance Application should be dated within 90 days of the time documentation is received by Rushmore.

Additional documentation may be required if income not supported.

HARDSHIP AFFIDAVIT

I (We) are having difficulty or expect to have difficulty making monthly mortgage payments because of the reason(s) set forth below. Please check the primary reason and submit the required documentation demonstrating your primary hardship.

If your Hardship Is:		Then the required documentation is:

Unemployment		Please state dates of unemployment
Unemployment		(e.g. MM/DD/YYYY to MM/DD/YYYY):
		(e.g. MM/DD/YYYY to MM/DD/YYYY):
		____/____/______ to ____/____/______
		____/____/______ to ____/____/______

Reduction in Income: a hardship that has		Provide a written description of your
caused a decrease in your income due to		circumstances on the attached hardship letter.
circumstances beyond your control (e.g.,
reduction in overtime or regular working hours,
reduction in base pay).

Increase in Housing Expenses: a hardship that		Provide a written description of your
has caused an increase in your housing expense		circumstances below or on the attached hardship
due to circumstances beyond your control.		letter:

	8

Divorce or legal separation; separation of	Provide one of the following documents:
borrowers unrelated by marriage, civil union or	∙	Divorce decree
domestic partnership.	∙	Divorce decree
domestic partnership.	∙	Separation Agreement
	∙	Separation Agreement
	∙ Current credit report evidencing divorce,
		separation or non-occupying borrower
		has different address
	∙ Recorded quitclaim deed evidencing that
		non-occupying borrower has relinquished
		rights to the property

Death of a borrower of death of a primary or	Send either:
secondary wage earner in the household.	∙	Death certificate
	∙	Death certificate
		OR
	∙ Obituary or newspaper article reporting
		the death

Long-term or permanent disability; serious	Provide one of the following documents:
illness of a borrower or dependent family	∙ Proof of monthly insurance benefits or
member.	∙ Proof of monthly insurance benefits or
member.		government assistance, if applicable
		government assistance, if applicable
	∙ Written statement or other
		documentation verifying disability or
		illness
	∙ Doctor’s certificate of illness or disability
	∙	Medical Bills
	None of the above shall require providing detailed
	medical information

Disaster (natural or man-made) adversely	Provide one of the following documents:
impacting the property or a borrower’s place of	∙	Insurance claim
employment.	∙	Insurance claim
employment.	∙ Federal Emergency Management Agency
	∙ Federal Emergency Management Agency
		grant or Small Business Administration
		loan paperwork
	∙ Proof of borrower or employer property
		located in a declared disaster area

Distant employment transfer/relocation	For active duty service members: Note of
	Permanent Change of Station (PCS) or actual PCS
	orders
	For employment transfers/new
	employment:
	One of:
	∙ Copy of signed offer letter/employer
	notice showing employment location
	∙ Pay-stub from new employer
	∙ if none of the above, written explanation
	Also provide documentation showing any
	relocation assistance

Business Failure	Tax Return from previous year (with schedules)
	AND
	Proof of business failure supported by one of the
	following:
	∙ Bankruptcy filing for business
	∙ 2 months recent bank statements for
	business account evidencing cessation of
	business activity
	∙ Most recent signed and dated quarter or
	year to date profit and loss statement

Other	Provide a written description of hardship below
	and any relevant documentation:

HARDSHIP LETTER

Please Complete:

Date: ________________

______________________________

Property Address

_______________________________

City, State, Zip Code

Loan Number: ______________________

My financial circumstances since entering into the above referenced loan have changed substantially and I am no longer financially able to maintain the loan payments.

The following changes or events have occurred and are preventing me from maintaining current and/or future payments on my loan.

__________________________________________________________________________

___________________________	______________
Borrower Signature	Date
___________________________	______________
Co-Borrower Signature	Date
	11

INFORMATION FOR GOVERNMENT MONITORING PURPOSES

For federal government programs, 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 service is required to note the information on the basis of visual observation or surname if you have made a request of loan modification in person. If you do not wish to furnish this information indicate below.

Borrower	Co-Borrower

I do not want to furnish this information	I do not want to furnish this information

Ethnicity:	Ethnicity:
Hispanic/Latino	Hispanic/Latino
Not Hispanic/Latino	Not Hispanic/Latino

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

Sex:	Sex:
Female	Female
Male	Male

BORROWER/CO-BORROWER ACKNOWLEDGEMENT AND AGREEMENT

I certify, acknowledge and agree as follows:

1.All information in this Borrower Assistance Application is truthful and the hardship I have identified as contributed to my need for mortgage relief.

2.The accuracy of my statements may be reviewed by Rushmore, the loan owner or guarantor of my loan, their agents or an authorized third party*, and I may be required to provide additional supporting documentation.

3.Knowingly submitting false information may violate federal and other applicable law.

4.If I have intentionally defaulted on my existing mortgage loan, engaged in fraud or misrepresented any fact(s) in connection with this application or if I do not provide all required documentation, Rushmore may cancel any mortgage relief granted and may pursue foreclosure on my property and/or pursue any available legal remedies.

5.Rushmore is not obligated to offer me assistance based solely on the representations in this application or other documentation submitted in connection with my request.

6.I may be eligible for a trial plan, repayment plan or forbearance plan. If I am eligible for one of these:

a.All the terms of this Acknowledgement and Agreement are incorporated into such plan.

b.My first timely payment under the plan will serve as acceptance of the terms set forth in the plan sent by Rushmore.

c.Rushmore’s acceptance of any payment under the plan will not be a waiver of any acceleration of my loan or foreclosure action that has occurred and will not cure my default unless such payments are sufficient to completely cure my entire default under my loan.

d.Payments due under a trial plan for modification generally require escrow amounts. If I was not previously required to pay escrow amounts and my trial plan contains escrow amounts, I agree to the establishment of an escrow account and agree that any prior waiver is revoked. Payments due under a repayment plan or forbearance plan may or may not contain escrow amounts. If I was not previously requirement to pay escrow amounts and my repayment plan for forbearance plan contains escrow amounts, I agree to the establishment of an escrow account and agree that any prior escrow waiver is revoked.

7.A condemnation notice has not been issued for the property.

8.Rushmore may obtain a current credit report on all borrowers obligated on the Note.

9.Rushmore or my designated representative or counseling agency will collect and record personal information that I submit in or related to this application and during the evaluation process. This personal information may include (a) my name, address and telephone number, (b) my social security number, (c) my credit score, (d) my income and (e) my payment history and information about my accounts and activity. I understand and consent to this as well as your disclosing this information and the terms of any relief granted to any investor, insurer or guarantor of my loan and if applicable, to the US Department of Treasury, Fannie Mae and Freddie Mac (and their agents) in conjunction with their responsibilities under the Making Home Affordable program.

10.I consent to being contacted concerning this request for mortgage assistance and all other matters concerning my loan at any e-mail address or cellular or mobile telephone number I have provided to Rushmore. This includes text messages and telephone calls (including those made by an automated dialer) to my cellular or mobile telephone.

___________________________	______________
Borrower Signature	Date
___________________________	______________
Co-Borrower Signature	Date
	13

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 if you may be eligible for assistance under the Making Home Affordable Program. 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 USC 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 understand that the Servicer, the United States Department of the Treasury or their respective agents may investigate the accuracy of my/our statements by performing routine background checks, including automated searches of federal, state or 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 application is received by the Servicer.

___________________________	__________________
Borrower Signature	Date
______________	__________________
Date of Birth	Social Security Number

___________________________	__________________
Co-Borrower Signature	Date
_______________	__________________
Date of Birth	Social Security Number

Use this form for an individual who resides at your property address or contributes to household income who is not listed as a borrower on the loan.

Borrower Name: __________________________ Loan Number: ______________________

Property Address: ___________________________________________________________

Non-Borrower Contributor Name: ______________________________________________

Non-Borrower Contributor Address: _____________________________________________

Non-Borrower Contributor Social Security No.: ____________________

My income has been previously used in an evaluation for a HAMP modification for a principal residence. Yes No

A mortgage of any other property I own has had a permanent HAMP modification.

Yes	No
Monthly Income

Gross Wages		$

Overtime		$

Child Support/Alimony*		$

Non-Taxable Social Security/SSDI		$

Taxable SS benefits or Other		$
Monthly Income (e.g., Annuities or
Retirement Plans, etc.)

Tips, Commissions, Bonus and		$
Self-Employment Income

Rents Received		$

Unemployment Income		$

Food stamps/Welfare		$

Other		$

*Child Support, alimony, separation maintenance need not be disclosed if you do not want it considered in support of your Loan payments.

By signing below, I agree to the following

∙I request that my income be included in the review of the modification request by the above referenced borrower(s).

∙I contribute/will contribute for the foreseeable future : (check one)

$ ____________________ monthly to the household

100% of my income

∙I will provide documentation supporting my income upon request.

∙I authorize Rushmore or its agents to obtain my credit report in connection with your evaluation of the Borrower’s request for assistance.

_______________________________	_________________
Signature of Non-Borrower Contributor	Date
	15

WILL INCOME DOCUMENTATION THAT I SUBMIT EXPIRE AT ANY POINT?

Any income documentation that you submit as part of your Borrower Assistance Application should be dated within 90 days of the time documentation is received by Rushmore. Generally, a decision will be made on your Borrower Assistance Application prior to the time that documentation you submit would expire.

Income documentation includes items that would document your monthly income, such as paycheck stubs and bank statements.

WILL I BE CONSIDERED FOR ALL TYPES OF LOSS MITIGATION OPTIONS?

We service loans for many different types of loan owners. Each loan owner decides what options to offer and when and under what circumstances they will be offered. Some loan owners may not offer loan modification options or may limit the number of times or the time periods during which it will offer certain options. Some loan owners may offer different options depending on whether the property is a primary residence, second home or investment property or is vacant. You will be considered for all loss mitigations that are offered by the particular owner of your loan for the particular type of loan that you have.

If your loan is a government-insured loan (e.g., FHA, VA or USDA), the government agency determines what options may be offered and when they may be offered.

WILL MY CREDIT SCORE BE AFFECTED?

We are required to report the delinquency status of your loan to the credit reporting agencies in accordance with the requirements of the Fair Credit Reporting Act and the Consumer Data Industry Association requirements.

The acceptance of a foreclosure prevention option may affect your credit score, depending on your individual credit history. Credit scoring companies generally consider entering into a plan with reduced payments as increasing your credit risk. Therefore, entering into a plan with reduced payments may adversely affect your credit score, particularly if you are current on your loan or otherwise have a good score.

WILL THERE BE ANY TAX CONSEQUENCES?

Depending on the loss mitigation option or terms of an option you are offered, there may be tax consequences to such a transaction. For example, debt forgiveness may be taxable income to you. Rushmore is not a law firm. You should consult your tax advisor or an attorney about any potential tax consequences of an offered loss mitigation option.

WILL YOU CONTINUE COLLECTION OR FORECLOSURE ACTIVITIES?

You should continue to make all required monthly payments on your loan if you can. We may continue collection and/or foreclosure activity as allowed under applicable federal and state laws until a foreclosure prevention option has been approved and is completed.

If you submit a complete Borrower Assistance Application, we will not commence a foreclosure proceeding unless:

oYou do not accept an offered option within the specified time period.

oYou are denied for all available options to foreclosure and any applicable appeal period has expired.

oYou breach the terms of the option you were offered and you accepted.

WHAT IF MY PROPERTY IS SCHEDULED FOR A FORECLOSURE SALE?

In general, we will not evaluate a Borrower Assistance Application that is submitted shortly before a scheduled foreclosure sale date. This means that, in general, in order for your Application to be evaluated, your complete Borrower Assistance Application must be received by Rushmore:

oIf the property is in Minnesota and is your primary residence: at least 7 business days prior to the scheduled foreclosure sale date

oFor all other loans: at least 38 calendar days prior to the scheduled foreclosure sale date

If a foreclosure sale is pending but there is no specific date scheduled for the sale, a court with jurisdiction over the foreclosure or a public official charged with carrying out the sale may not halt the sale even if we approve you for a foreclosure alternative prior to the sale.

WILL I NEED AN APPRAISAL ON MY HOME?

Depending on the type of option, you may receive a call from a property appraiser and/or real estate broker to make arrangements to gain access to your property to determine its value. The cost of the appraisal will be added to your loan account.

WHAT IF I AM AN ACTIVE SERVICE MEMBER?

The Service members Civil Relief Act provides certain legal protections and debt relief to service members on active duty or the dependents of active service members. Please visit www.militaryonesource.com for information and assistance with budgeting, debt reduction and credit issues or call toll free from within the U.S. at 800-342-9647 or from outside the U.S. at 800-342-6477 or International Collect at 484-530-5908. Please let Rushmore know if you are an active service member experiencing financial difficulty. Even if you are not entitled to protection under the Service members Civil Relief Act, Rushmore may be able to help you under its service members relief program.

ARE THERE OTHER RESOURCES AVAILABLE TO ME?

The U.S. Department of Housing and Urban Development (HUD) sponsors non-profit homeownership counseling agencies across the country. Call 800-569-4287 or visit http://www.hud.gov/offices/hsg/sfh/hcc/hcs.cfm for a list of HUD-approved agencies in your area. In addition, many state regulatory authorities maintain lists of non-profit homeownership counseling agencies available to borrowers in that state. The New York State Department of Financial Services website (www.dfs.ny.gov) or the Division of Housing and Community Renewal's website (www.nyshcr.org) can provide names of counseling agencies assisting New York borrowers. For borrowers in other states, please check your state's regulatory websites.

DISCLOSURE OF RIGHT TO RECEIVE COPY OF APPRAISAL OR VALUATION REPORT

In connection with your recent loss mitigation request we may order an appraisal or valuation to determine the property's value, and may charge you for this appraisal or valuation. You have the right to receive a copy of any appraisal or valuation that is performed on your property. Upon completion, Rushmore will promptly provide you with a copy of any appraisal or valuation, even if your application is not approved. You can pay for an additional appraisal for your own use at your own cost.

Please keep this notice with your own records.

If you have other mortgage loans secured by this property, you should contact the servicer of those loans to discuss available loss mitigation options.

GLOSSARY OF CERTAINȄ LOSSMITIGATION OPTIONTERMS Ǥ Repayment Plan Ǥ Ǥ

Ȅ Ǥ Trial PeriodPlan/Forbearance Ǥ Ǥ ȋ

Ȍ Ǥ ̵ Ǥ Ǥ Ǥ Ǥ Ǥ Ǥ Ǥ Ǥ

Ȅ Ǥ Ǥ LoanModification ǣ

Ȅ Ǥ Ǥ Short Refinance Ǥ

Ǧ Ǥ Ǥ Short Sale ȋǤǤ ȌǤ Ǥ

Ȅ Ǧ Ǧ Ǥ DeedinLieu Ǥ

Ǥ Ǥ Ǥ ǦǦ Ǥ Ǥ

Ȅ ReinstatementǤ Ǥ Ǥ

Ȅ ǦǦ Ǥ ConsentǤto Judgment Ǥ

Ȅ Settlement Ǥ Ǥ

Form 4506-T

(July 2017)

Department of the Treasury Internal Revenue Service

Request for Transcript of Tax Return

Do not sign this form unless all applicable lines have been completed.

Request may be rejected if the form is incomplete or illegible.

For more information about Form 4506-T, visit www.irs.gov/form4506t.

OMB No. 1545-1872

Tip. Use Form 4506-T to order a transcript or other return information free of charge. See the product list below. You can quickly request transcripts by using our automated self-help service tools. Please visit us at IRS.gov and click on “Get a Tax Transcript...” under “Tools” or call 1-800-908-9946. If you need a copy of your return, use Form 4506, Request for Copy of Tax Return. There is a fee to get a copy of your return.

1a	Name shown on tax return. If a joint return, enter the name	1b First social security number on tax return, individual taxpayer identification
	shown first.	number, or employer identification number (see instructions)

2a	If a joint return, enter spouse’s name shown on tax return.	2b Second social security number or individual taxpayer
		identification number if joint tax return

3Current name, address (including apt., room, or suite no.), city, state, and ZIP code (see instructions)

4Previous address shown on the last return filed if different from line 3 (see instructions)

5If the transcript or tax information is to be mailed to a third party (such as a mortgage company), enter the third party’s name, address, and telephone number.

Caution: If the tax transcript is being mailed to a third party, ensure that you have filled in lines 6 through 9 before signing. Sign and date the form once you have filled in these lines. Completing these steps helps to protect your privacy. Once the IRS discloses your tax transcript to the third party listed on line 5, the IRS has no control over what the third party does with the information. If you would like to limit the third party’s authority to disclose your transcript information, you can specify this limitation in your written agreement with the third party.

6Transcript requested. Enter the tax form number here (1040, 1065, 1120, etc.) and check the appropriate box below. Enter only one tax form number per request.

aReturn Transcript, which includes most of the line items of a tax return as filed with the IRS. A tax return transcript does not reflect

changes made to the account after the return is processed. Transcripts are only available for the following returns: Form 1040 series, Form 1065, Form 1120, Form 1120-A, Form 1120-H, Form 1120-L, and Form 1120S. Return transcripts are available for the current year and returns processed during the prior 3 processing years. Most requests will be processed within 10 business days . . . . . .

bAccount Transcript, which contains information on the financial status of the account, such as payments made on the account, penalty assessments, and adjustments made by you or the IRS after the return was filed. Return information is limited to items such as tax liability

and estimated tax payments. Account transcripts are available for most returns. Most requests will be processed within 10 business days .

cRecord of Account, which provides the most detailed information as it is a combination of the Return Transcript and the Account

Transcript. Available for current year and 3 prior tax years. Most requests will be processed within 10 business days

. . . . . .

7Verification of Nonfiling, which is proof from the IRS that you did not file a return for the year. Current year requests are only available

after June 15th. There are no availability restrictions on prior year requests. Most requests will be processed within 10 business days . .

8Form W-2, Form 1099 series, Form 1098 series, or Form 5498 series transcript. The IRS can provide a transcript that includes data from these information returns. State or local information is not included with the Form W-2 information. The IRS may be able to provide this

transcript information for up to 10 years. Information for the current year is generally not available until the year after it is filed with the IRS. For example, W-2 information for 2011, filed in 2012, will likely not be available from the IRS until 2013. If you need W-2 information for retirement purposes, you should contact the Social Security Administration at 1-800-772-1213. Most requests will be processed within 10 business days .

Caution: If you need a copy of Form W-2 or Form 1099, you should first contact the payer. To get a copy of the Form W-2 or Form 1099 filed with your return, you must use Form 4506 and request a copy of your return, which includes all attachments.

9Year or period requested. Enter the ending date of the year or period, using the mm/dd/yyyy format. If you are requesting more than four years or periods, you must attach another Form 4506-T. For requests relating to quarterly tax returns, such as Form 941, you must enter

each quarter or tax period separately.	/	/	/	/	/	/	/	/

Caution: Do not sign this form unless all applicable lines have been completed.

Signature of taxpayer(s). I declare that I am either the taxpayer whose name is shown on line 1a or 2a, or a person authorized to obtain the tax information requested. If the request applies to a joint return, at least one spouse must sign. If signed by a corporate officer, 1 percent or more shareholder, partner, managing member, guardian, tax matters partner, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify that I have the authority to execute Form 4506-T on behalf of the taxpayer. Note: This form must be received by IRS within 120 days of the signature date.

Signatory attests that he/she has read the attestation clause and upon so reading declares that he/she has the authority to sign the Form 4506-T. See instructions.

Phone number of taxpayer on line 1a or 2a

	Signature (see instructions)	Date
Sign
Here
Here	Title (if line 1a above is a corporation, partnership, estate, or trust)


	Spouse’s signature	Date

For Privacy Act and Paperwork Reduction Act Notice, see page 2.		Cat. No. 37667N	Form 4506-T (Rev. 7-2017)

Form 4506-T (Rev. 7-2017)	Page 2

Section references are to the Internal Revenue Code unless otherwise noted.

Future Developments

For the latest information about Form 4506-T and its instructions, go to www.irs.gov/form4506t. Information about any recent developments affecting Form 4506-T (such as legislation enacted after we released it) will be posted on that page.

General Instructions

Caution: Do not sign this form unless all applicable lines have been completed.

Purpose of form. Use Form 4506-T to request tax return information. You can also designate (on line 5) a third party to receive the information. Taxpayers using a tax year beginning in one calendar year and ending in the following year (fiscal tax year) must file Form 4506-T to request a return transcript.

Note: If you are unsure of which type of transcript you need, request the Record of Account, as it provides the most detailed information.

Tip. Use Form 4506, Request for Copy of Tax Return, to request copies of tax returns.

Automated transcript request. You can quickly request transcripts by using our automated self-help service tools. Please visit us at IRS.gov and click on “Get a Tax Transcript...” under “Tools” or call 1-800-908-9946.

Where to file. Mail or fax Form 4506-T to the address below for the state you lived in,

or the state your business was in, when that return was filed. There are two address charts: one for individual transcripts (Form 1040 series and Form W-2) and one for all other transcripts.

If you are requesting more than one transcript or other product and the chart below shows two different addresses, send your request to the address based on the address of your most recent return.

Chart for individual transcripts (Form 1040 series and Form W-2 and Form 1099)

If you filed an

individual return Mail or fax to: and lived in:

Alabama, Kentucky,
Louisiana, Mississippi,
Tennessee, Texas, a	Internal Revenue Service
foreign country, American	RAIVS Team
Samoa, Puerto Rico,	Stop 6716 AUSC
Guam, the	Austin, TX 73301
Commonwealth of the
Northern Mariana Islands,
the U.S. Virgin Islands, or	855-587-9604
A.P.O. or F.P.O. address

Alaska, Arizona, Arkansas,
California, Colorado,
Hawaii, Idaho, Illinois,	Internal Revenue Service
Indiana, Iowa, Kansas,	RAIVS Team
Michigan, Minnesota,	Stop 37106
Montana, Nebraska,	Fresno, CA 93888
Nevada, New Mexico,
North Dakota, Oklahoma,
Oregon, South Dakota,
Utah, Washington,	855-800-8105
Wisconsin, Wyoming

Connecticut, Delaware,
District of Columbia,
Florida, Georgia, Maine,	Internal Revenue Service
Maryland, Massachusetts,	RAIVS Team
Missouri, New Hampshire,	Stop 6705 P-6
New Jersey, New York,	Kansas City, MO 64999
North Carolina, Ohio,
Pennsylvania, Rhode
Island, South Carolina,
Vermont, Virginia, West	855-821-0094
Virginia

Chart for all other transcripts

	If you lived in
	or your business	Mail or fax to:
	was in:

	Alabama, Alaska,
	Arizona, Arkansas,
	California, Colorado,
	Florida, Hawaii, Idaho,
	Iowa, Kansas,
	Louisiana, Minnesota,
	Mississippi,	Internal Revenue Service
	Missouri, Montana,	RAIVS Team
	Nebraska, Nevada,	P.O. Box 9941
	New Mexico,	Mail Stop 6734
	North Dakota,	Ogden, UT 84409
	Oklahoma, Oregon,
	South Dakota, Texas,
	Utah, Washington,
	Wyoming, a foreign
	country, American	855-298-1145
	Samoa, Puerto Rico,
	Guam, the
	Commonwealth of the
	Northern Mariana
	Islands, the U.S. Virgin
	Islands, or A.P.O. or
	F.P.O. address

	Connecticut,
	Delaware, District of
	Columbia, Georgia,	Internal Revenue Service
	Illinois, Indiana,	Internal Revenue Service
	Illinois, Indiana,	RAIVS Team
	Kentucky, Maine,	RAIVS Team
	Kentucky, Maine,	P.O. Box 145500
	Maryland,	P.O. Box 145500
	Maryland,	Stop 2800 F
	Massachusetts,	Stop 2800 F
	Massachusetts,	Cincinnati, OH 45250
	Michigan, New	Cincinnati, OH 45250
	Michigan, New
	Hampshire, New
	Jersey, New York,
	North Carolina,
	Ohio, Pennsylvania,
	Rhode Island, South	855-800-8015
	Carolina, Tennessee,	855-800-8015
	Carolina, Tennessee,
	Vermont, Virginia,
	West Virginia,
	Wisconsin

Line 1b. Enter your employer identification number (EIN) if your request relates to a business return. Otherwise, enter the first social security number (SSN) or your individual taxpayer identification number (ITIN) shown on the return. For example, if you are requesting Form 1040 that includes Schedule C (Form 1040), enter your SSN.

Line 3. Enter your current address. If you use a P.O. box, include it on this line.

Line 4. Enter the address shown on the last return filed if different from the address entered on line 3.

Note: If the addresses on lines 3 and 4 are different and you have not changed your address with the IRS, file Form 8822, Change of Address. For a business address, file Form 8822-B, Change of Address or Responsible Party — Business.

Line 6. Enter only one tax form number per request.

Signature and date. Form 4506-T must be signed and dated by the taxpayer listed on line 1a or 2a. The IRS must receive Form 4506-T within 120 days of the date signed by the taxpayer or it will be rejected. Ensure that all applicable lines are completed before signing.

	You must check the box in the signature
!	area to acknowledge you have the
!	authority to sign and request the

information. The form will not be CAUTION processed and returned to you if the

box is unchecked.

Individuals. Transcripts of jointly filed tax returns may be furnished to either spouse. Only one signature is required. Sign Form 4506-T exactly as your name appeared on the original return. If you changed your name, also sign your current name.

Corporations. Generally, Form 4506-T can be signed by: (1) an officer having legal authority to bind the corporation, (2) any person designated by the board of directors or other governing body, or (3) any officer or employee on written request by any principal officer and attested to by the secretary or other officer. A bona fide shareholder of record owning 1 percent or more of the outstanding stock of the corporation may submit a Form 4506-T but must provide documentation to support the requester's right to receive the information.

Partnerships. Generally, Form 4506-T can be signed by any person who was a member of the partnership during any part of the tax period requested on line 9.

All others. See section 6103(e) if the taxpayer has died, is insolvent, is a dissolved corporation, or if a trustee, guardian, executor, receiver, or administrator is acting for the taxpayer.

Note: If you are Heir at law, Next of kin, or Beneficiary you must be able to establish a material interest in the estate or trust.

Documentation. For entities other than individuals, you must attach the authorization document. For example, this could be the letter from the principal officer authorizing an employee of the corporation or the letters testamentary authorizing an individual to act for an estate.

Signature by a representative. A representative can sign Form 4506-T for a taxpayer only if the taxpayer has specifically delegated this authority to the representative on Form 2848, line 5. The representative must attach Form 2848 showing the delegation to Form 4506-T.

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to establish your right to gain access to the requested tax information under the Internal Revenue Code. We need this information to properly identify the tax information and respond to your request. You are not required to request any transcript; if you do request a transcript, sections 6103 and 6109 and their regulations require you to provide this information, including your SSN or EIN. If you do not provide this information, we may not be able to process your request. Providing false or fraudulent information may subject you to penalties.

Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation, and cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by section 6103.

The time needed to complete and file Form 4506-T will vary depending on individual circumstances. The estimated average time is: Learning about the law or the form, 10 min.; Preparing the form, 12 min.; and Copying, assembling, and sending the form to the IRS, 20 min.

If you have comments concerning the accuracy of these time estimates or suggestions for making Form 4506-T simpler, we would be happy to hear from you. You can write to:

Internal Revenue Service

Tax Forms and Publications Division

1111 Constitution Ave. NW, IR-6526

Washington, DC 20224

Do not send the form to this address. Instead, see Where to file on this page.

Question	Answer
Form Name	Rushmore Loan Management Services Form
Form Length	23 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	5 min 45 sec
Other names	assistance plan rushmore, the borrower assistance form, assistance information rushmore, assistance application rushmore

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