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UNIFORM BORROWER ASSISTANCE FORM

If you are experiencing a temporary or long-term hardship and need help, you must complete and submit this form along with other required

documentation to be considered for available solutions. On this page, you must disclose information about (1) you and your intentions to either keep

o t a sitio out of ou ho e; the p ope t ’s status; eal estate ta es; ho eo e ’s i su a e p e iu s; 5) bankruptcy; (6) your credit counseling agency, and (7) other liens, if any, on your property.

On Page 2 you must disclose information about all of your income, expenses and assets. Page 2 also lists the required income documentation that you must submit in support of your request for assistance. The on Page 3, you must 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.

NOTICE: In addition, when you sign and date this form, you will make important certifications, representations and agreements, including certifying that all of the information in this Borrower Assistance Form is accurate and truthful and any identified hardship has contributed to your submission of this request for mortgage relief.

REMINDER: The Borrower Response Package you need to return consists of: (1) this completed, signed and dated Borrower Assistance Form; (2) completed and signed IRS Form 4506T-EZ; (3) required income documentation, and (4) required hardship documentation.

Loan I.D. Number		(usually found on your monthly mortgage statement)

I want to:	 Keep the property  Sell the property  Deed the property to lienholder

The property is currently:  My Primary Residence			 A Second Home  An Investment Property

Provide verification of occupancy (i.e. cable/cell phone bill)

The property is currently:  Owner Occupied			 Renter Occupied		 Vacant
		Borrower			Co-Borrower/Non-Obligor
BORROWER’“ NAME				CO-BORROWER’“ NAME

SOCIAL SECURITY NUMBER		DATE OF BIRTH		SOCIAL SECURITY NUMBER		DATE OF BIRTH

HOME PHONE NUMBER WITH AREA CODE				HOME PHONE NUMBER WITH AREA CODE

CELL OR WORK NUMBER WITH AREA CODE				CELL OR WORK NUMBER WITH AREA CODE

Selene is authorized to call and text this cell phone number for loss				Selene is authorized to call and text this cell phone number for loss mitigation
mitigation efforts	 Yes  No			efforts	 Yes  No

BEST TIME TO CALL				BEST PHONE NUMBER TO CALL

MAILING ADDRESS

PROPERTY ADDRESS (IF SAME AS MAILING ADDRESS, JUST WRITE SAME)

EMAIL ADDRESS

Estimated value: $

Have you contacted a credit-counseling agency for help?  Yes No

Is the property listed for sale?  Yes

 No

If yes, please complete the counselor contact information below:

If yes, what was the listing date?

Listing Price? $

Cou

selo ’s Na

Age

’s Na

If property has been listed for sale, have you received an offer on the

property?  Yes

 No

Cou

selo ’s Pho

e Nu e :

Date of offer:

Amount of Offer: $

Cou

selo ’s E

ail Add ess:

Age

t’s Na

Age

t’s Pho

e Nu

e :

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:

Have you filed for bankruptcy?

 Yes

 No

If yes:

 Chapter 7  Chapter 13

Filing Date:

Has your bankruptcy been discharged?  Yes

 No

Bankruptcy case number:

Selene Loss Mitigation Application

Page 1 of 13

UNIFORM BORROWER ASSISTANCE FORM

Monthly Household

Monthly Household Debt

Household Assets (associated with

Monthly Household

Income

the property and/or borrower(s)

Expenses

Monthly Gross

First Mortgage

Checking Account (s)

Food

wages

Payment

Overtime

Second Mortgage

Checking Account (s)

Water / Gas /

Payment

Electric

Child

Ho eo

e ’s

Savings or

Money Market

Transportation

Support/Alimony*

Insurance

Acct(s)

Non-taxable social

Property Taxes

CDs

Child Care

security/SSDI

Taxable SS

Credit Cards /

Installment

benefits or other

Loan(s) (total

Life / Auto

monthly income

Stocks / Bonds

minimum

Insurance

from annuities or

payment per

retirement plans

month)

Tips, commissions,

HOA/Condo

Cable /

bonus and self-

Fees/Property

Other Cash on Hand

Satellite

employed income

Maintenance

Rents Received

Car Lease

Other Real Estate

Religious /

Payments

(estimated value)

Charity

Unemployment

Alimony, Child

401K / 403B / IRA

MISC

Income

Support Payments

Expenses

Food

Mortgage

Payments on

Other

Stamps/Welfare

other properties

Other

Total (Gross

Total Debt

Total Assets

Total

income)

Expenses

*Notice: Alimony, child support, or separate maintenance income need not be revealed if you do not choose to have it considered for repaying this loan.

Additional Properties Owned:

Address/Mortgage Company

Rents

Mortgage

(Rental, 2nd Home, Primary)

Required Income Documentation – For All Household Members and Mortgagors

Do you earn a wage?

Are you self-employed?

For each borrower who is a salaried employee or hourly wage

For each borrower who receives self-employed income, include two years of

earner, include the most recent pay stub that reflects at least

completed, signed individual federal income tax returns and, as applicable, the

30 days of year-to-date earnings for each borrower.

business tax return; AND either the most recent signed and dated quarterly or

(w-2’s, tax retur

s, 2 ba k state

e ts (all pages, all

year-to-date profit/loss statement that reflects activity for the most recent

accounts))

three months; OR copies of bank statements for all accounts for the last six

Employer: ______________________

months evidencing continuation of business activity.

Date of Hire: ___________________

 Seasonal Worker/Teacher?

Annual Start Date :________________ Annual End Date: _________________ Average Months worked per yr: ____________

 Do you have any additional sources of income? Provide for each borrower as applicable:

Other Ear ed I

o e su h as o

uses,

o issio

s, housi g allo a

e, tips, or o erti e:

 Reliable third-party documentation describing the amount and nature of the income (e.g., employment contract or printouts documenting tip income).

Social Security, disability or death benefits, pension, public assistance, or adoption assistance:

 Documentation showing the amount and frequency of the benefits, such as letters, exhibits, disability policy or benefits statement from the provider, and

 Documentation showing the receipt of payment, such as copies of the two most recent bank statements showing deposit amounts.

Rental income:

 Copy of the most recent filed federal tax return with all schedules, including Schedule E – Supplement Income and Loss. Rental income for qualifying purposes will

be 75% of the gross rent reduced by the monthly debt service on the property, if applicable; or

 If rental income is not reported on Schedule E – Supplemental Income and Loss, provide a copy of the current lease agreement with either bank statements or

cancelled rent checks demonstrating receipt of rent.

Investment income:

 Copies of the two most recent investment statements or bank statements supporting receipt of this income.

Selene Loss Mitigation Application

Page 2 of 13

Alimony, child support, or separation maintenance payments as qualifying income:*

Copy of divorce decree, separation agreement, or other written legal agreement filed with a court, or court decree that states the amount of the alimony, child support, or separation maintenance payments and the period of time over which the payments will be received, and

Copies of your two most recent bank statements or other third-party documents showing receipt of payment.

*Notice: Alimony, child support, or separate maintenance income need not be revealed if you do not choose to have it considered for repaying this loan.

UNIFORM BORROWER ASSISTANCE FORM

HARDSHIP AFFIDAVIT

(provide a written explanation with this request describing the specific nature of your hardship)

I am requesting review of my current financial situation to determine whether I quality for temporary or permanent mortgage relief options.

Date Hardship Began is:

I believe that my situation is:

Short-term (under 6 months)

Medium-term (6 – 12 months)

Long-term or Permanent Hardship (greater than 12 months)

I am having difficulty making my monthly payment because of reasons set forth below:

(Please check all that apply and submit required documentation demonstrating your hardship)

If Your Hardship is:	Then the Required Hardship Documentation is:

 Unemployment	 State Unemployment Letter, Unemployment Compensation Form 1099 G for the
Start Date: _________ End Date: _______	time frames listed or tax returns for those year(s).

 Underemployment	 Pa stu s, W ’s, a d Tax Returns for the time frames during which you were
	underemployed.

Income reduction (e.g., elimination of  Pa stu s, W ’s, a d tax returns for the time frames during which your income was

overtime, reduction in regular working	reduced. Income Before: __________Income After: _____________________
hours, or a reduction in base pay)
 Increase in Household Expenses	 Tax returns to support increase in number of dependents

Divorce or legal separation; Separation  Divorce decree signed by the court; OR

of Borrowers unrelated by marriage,	 Separation agreement signed by the court; OR
civil union or similar domestic	 Recorded quitclaim deed evidencing that the non-occupying Borrower or co-
partnership under applicable law	Borrower has relinquished all rights to the property

 Death of a borrower or death of either	 Original Death certificate; OR
the primary or secondary wage earner	 Obituary or newspaper article reporting the death
in the household	 Probated Will

Long-term or permanent disability;  Do to ’s e tifi ate of ill ess o disa ilit ; OR

Serious illness of a borrower/co-	 Medical bills; OR
borrower or dependent family	 Proof of monthly insurance benefits or government assistance (if applicable)
member
 Disaster (natural or man-made)	 Insurance claim; OR
adversely impacting the property or	 Federal Emergency Management Agency grant or Small Business Administration loan;
Bo o e ’s pla e of e plo e t	OR
	 Borrower or Employer property located in a federally declared disaster area

 Distant employment transfer	 For active duty service members: Notice of Permanent Change of Station (PCS) or
	actual PCS orders.
	 For employment transfers/new employment:

Copy of signed offer letter or notice from employer showing transfer to a new employment location,

Paystub from new employer, or

Written explanation (if neither item listed above is applicable).

In addition, documentation that reflects the amount of any relocation assistance provided, if applicable (not required for those with PCS orders).

Selene Loss Mitigation Application

Page 3 of 13

Business Failure

Tax return from the previous year (including all schedules) AND

Proof of business failure supported by one of the following:

∙Bankruptcy filing for the business; or

∙Two months recent bank statements for the business account evidencing cessation of business activity; or

∙Most recent signed and dated quarterly or year-to-date profit and loss statement

UNIFORM BORROWER ASSISTANCE FORM

Borrower/Co-Borrower Acknowledgement and Agreement

1.I certify that all of the information in this Borrower Assistance Form 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, owner or guarantor of my mortgage, or their agent(s) 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 understand the Servicer will obtain a current credit report on all borrowers obligated on the Note.

4.I understand that if I have intentionally default on my existing mortgage, engaged in fraud or misrepresented any fact(s) in connection with this request for mortgage relief or if I do not provide all required documentation, the Servicer may cancel any mortgage relief granted and may pursue foreclosure on my home and/or pursue any available legal remedies.

5.I certify that my property has not received 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 this information 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.If I am eligible for a trial period plan, repayment plan, or forbearance plan, and I accept and agree to all terms of such plan, I also

agree that the terms of this Acknowledgment and Agreement are incorporated into such plan by reference as if set forth in such pla i full. M fi st ti el pa e t follo i g “e i e ’s dete i atio a d otifi atio of eligi ilit o p e ualification

for a trial period plan, repayment plan, or forbearance plan (when applicable) will serve as acceptance of the terms set forth in the notice sent to me that sets forth the terms and conditions of the trial period plan, repayment plan, or forbearance plan.

9.I agree that when the Servicer accepts and posts a payment during the term of any repayment plan, trial period plan, or forbearance plan it will be without prejudice to, and will not be deemed a waiver of, the acceleration of my loan of foreclosure action and related activities and shall not constitute a cure of my default under my loan unless such payments are sufficient to completely cure my entire default under my loan.

10.I agree that any prior waiver as to my payment of escrow items to the Servicer in connection with my loan has been revoked.

11.If I qualify for and enter into a repayment plan, forbearance plan, and trial period plan, I agree to the establishment of an escrow account and the payment of escrow items if an escrow account never existed on my loan.

12.I understand that the Servicer will collect and record personal information that I submit in this Borrower Response Package and

during the evaluation process, including, but not limited to, my name, address, telephone number, social security number,

credit score, income, payment history, and information about my account balances and activity. I understand and consent to the “e i e ’s dis losu e of pe so al i fo atio a d the te s of a elief o fo e losu e alte ati e that I e ei e to any

investor, insurer, guarantor, or servicer that owns, insures, guarantees, or services my first lien or subordinate lien (if applicable) mortgage loan(s) or to any HUD-certified housing counselor.

13.If I am eligible for foreclosure prevention relief under the federal Making Home Affordable Program, I understand and consent to the disclosure of my personal information and the terms of any Making Home Affordable Agreement by the 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, and (c) companies that perform support services in conjunction with Making Home Affordable.

14.I consent to being contacted concerning this request for mortgage assistance at any cellular or mobile telephone number I have provided to the Lender. This includes text messages, telephone calls and emails to my cellular or mobile telephone.

Selene Loss Mitigation Application

Page 4 of 13

Borrower Signature

Date

Co-Borrower Signature

Date

Selene Loss Mitigation Application

Page 5 of 13

Question	Answer
Form Name	Selene Form
Form Length	13 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min 15 sec
Other names	selene form, seq, Servicer, selene financials com loss mitigation form pdf printable

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