Uniform Borrower Assistance Form – Fill Out and Use This PDF

Loan Number: 1004848

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 or transition out of your home; (2) information on the property's status; (3) real estate taxes; (4) homeowner's insurance premiums; (5) bankruptcy; (6) your credit counseling agency, and (7) information concerning other liens, if any, on your property.

On Page 2, you must disclose information about all of your income, expenses, and assets. Page 3 also lists the required income documentation that you must submit in support of your request for assistance. Then on Page 4, you must complete the Hardship Affidavit in which you disclose the nature of your hardship. It also tells you 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 (4506T for self-employed borrowers or borrowers with rental income); (3) required income documentation, and (4) required hardship documentation.

I want to:

Keep the Property

Vacate the Property

Sell the Property

Undecided

The property is currently:

My Primary Residence

A Second Home

An Investment Property

The property is currently:

Owner Occupied

Renter occupied

Vacant

BORROWER

CO-BORROWER

BORROWER'S NAME: John Loan Mod

CO-BORROWER'S NAME: Jane Smith

SOCIAL SECURITY

DATE OF BIRTH

NO. OF

SOCIAL SECURITY

DATE OF BIRTH

NO. OF

NUMBER

Sep 12, 1978

DEPENDENTS:

NUMBER

Sep 20, 1978

DEPENDENTS:

678 - 68 - 8767

678 - 68 - 8767

HOME PHONE NUMBER WITH AREA CODE

HOME PHONE NUMBER WITH AREA CODE

(342) 534 - 3425

(523) 453 - 2534

CELL OR WORK NUMBER WITH AREA CODE

CELL OR WORK NUMBER WITH AREA CODE

(305) 606 - 2360

(234) 324 - 3243

MAILING ADDRESS

1111 1st St, New Roads, LA 12121.

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

EMAIL ADDRESS

1111 1st St, New Roads, LA 12121.

craig@pixelfusion.com

Is the property listed for sale?

Yes

No

Have you contacted a credit-counseling agency for help?

If yes:

Yes

No

what was the listing date? ___________________

If yes:

Have you received an offer on the property?

Counselor's Name: John SMoth

Yes

No

Agency's Name:

_______________________________________________

Date of offer: ___________________

Counselor's Phone Number: (987) 897 - 9879 Ext 89789

Amount of Offer: $ 0.00

Counselor's Email Address:

Agent's Name:

john@counselor.com

Agent's Phone Number:

_______________________________________________

Is the property for sale by owner?

Yes

No

Do you have condominium or

Yes

No

Have you filed for bankruptcy?

Yes

No

homeowner association (HOA) fees?

If yes:

If yes: Total monthly amount: $ 100.00

Chapter 7

Chapter 11

Chapter 12

Chapter 13

Amount Past Due: $ __________________

Filing date: ___________________

Name and address fees are paid to:

Has your bankruptcy been discharged?

Yes

No

______________________________________________

__________________________________________

Bankruptcy case number:

___________________

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Loan Number: 1004848

Is any borrower an active duty service member?										Yes	No
Is any borrower the spouse or dependent of an active duty service member?										Yes	No
Has any borrower been deployed away from his/her primary residence or recently received a Permanent Change of										Yes	No
Station order?
Is any borrower the surviving spouse of a deceased service member who was on active duty at the time of death?										Yes	No
Is any borrower a dependent of a deceased service member who was on active duty at the time of death?										Yes	No
Monthly Household Income							Household Assets (associated with
							the property and/or borrower(s)
Gross wages				$4,400.00		Checking Account(s)					$3,400.00
Overtime				$0		Checking Account(s)					$
Child Support / Alimony*				$0		Savings / Money Market					$1,000.00
Non-taxable social security/SSDI				$0		CDs					$
Taxable SS benefits or other monthly income from				$0		Stocks / Bonds					$0
annuities or retirement plans
Tips, commissions, bonus and self-employed income				$0		Other Cash on Hand					$200.00
Rents Received				$0		Other Real Estate (estimated value)					$0
Unemployment Income				$0		Other_____________					$374,000.00
Food Stamps/Welfare				$0
Other_____________				$0
Total (Gross income)				$4,400.00		Total (assets)					$378,600.00
			MONTHLY HOUSEHOLD EXPENSES/DEBT
Monthly Debt Expenses							Monthly Household Expenses
First mortgage payment	$1,872.96		Cable				$50.00		Tuition		$0
Second mortgage payment	$0		Bankruptcy trustee				$		Gas / fuel / oil for vehicle		$
			payments
Homeowner's Insurance	$237.11		Bus / transit / parking				$0		Ground rent / land lease		$
Property taxes	$110.00		Internet				$0		Health insurance		$150.00
Credit cards / installment	$325.00		Charitable giving				$0		Medical bills		$0
loans(total minimum
payment / mo.)
Car lease payments	$125.00		Child care				$155.00		Life insurance		$
HOA/condo fees/property	$100.00		Clothes				$0		Prescriptions		$
maintenance
Mortgage payments on	$0		Entertainment				$325.00		Phones (land and/or cell)		$0
other properties
Alimony payments			Legal / court costs				$		Food		$0
Child support payments	$0		Tax payments				$		Gas / electricity / fuel oil /		$0
									water / sewer / garbage
Other	$0		Vehicle insurance				$350.00		Other		$0
Total (debt expenses)			Total (household expenses)								$3,800.07

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Loan Number: 1004848

If subordinate lien(s) or any other lien(s) exist on the subject property, please enter information on the lien(s) below:

Lien Holder's Name:	Balance and Interest Rate:	Loan Number:	Lien Holder's Phone Number:
__________________________	0.00/1.000	_________________________
__________________________
__
	/
	/
	REQUIRED INCOME DOCUMENTATION

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

"Other Earned Income" such as bonuses, commissions, housing allowance, tips, or overtime:

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 you reported 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. 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.

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Loan Number: 1004848

HARDSHIP AFFIDAVIT

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

Date Hardship Began is: May 10, 2012

Has your hardship ended? No	Yes If yes, what date was it resolved? ___________________________
My hardship situation is:
Short-term (under 6 months)	Medium-term (6-12 months)	Long-term or Permanent
		(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	No hardship documentation required
Reduction in Income: a hardship that has caused a	No hardship documentation required
decrease in your income due to circumstances outside
your control (e.g., elimination of overtime, reduction in
regular working hours, a reduction in base pay)
Increase in Housing Expenses: a hardship that has	No hardship documentation required
caused an increase in your housing expenses due to
circumstances outside your control
Divorce or legal separation; Separation of	Divorce decree signed by the court; OR
Borrowers unrelated by marriage, civil union or similar	Separation agreement signed by the court; OR
domestic partnership under applicable law	Current credit report evidencing divorce, separation, or non-occupying borrower
	has a different address; OR
	Recorded quitclaim deed evidencing that the non-occupying Borrower or
	co-Borrower has relinquished all rights to the property
Death of a borrower or death of either the primary	Death certificate; OR
or secondary wage earner in the household	Obituary or newspaper article reporting the death
Long-term or permanent disability; Serious illness	Doctor's certificate of illness or disability; OR
of a borrower/co-borrower or dependent family	Medical bills; OR
member	Proof of monthly insurance benefits or government assistance (if applicable)
Disaster (natural or man-made) adversely	Insurance claim; OR
impacting the property or Borrower's place of	Federal Emergency Management Agency grant or Small Business
employment	Administration loan; OR
	Borrower or Employer property located in a federally declared disaster area
Distant employment transfer / Relocation	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; OR
	Pay stub from new employer; OR
	If none of these apply, provide written explanation
	In addition to the above, documentation that reflects the amount of any relocation
	assistance provided, if applicable (not required for those with PCS orders).
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

Other: a hardship that is not covered above	Written explanation describing the details of the hardship and relevant
	documentation

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Loan Number: 1004848

Borrower/Co-Borrower Acknowledgement and Agreement

I certify, acknowledge, and agree to the following:

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

2.The accuracy of my statements may be reviewed by the Servicer, owner or guarantor of my mortgage, their agent(s), or an authorized third party*, and I may be required to provide additional supporting documentation. I will provide all requested documents and will respond timely to all Servicer, or authorized third party*, communications.

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

4.If I have intentionally defaulted 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.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.

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

a.All the terms of this Acknowledgment and Agreement are incorporated into such plan by reference as if set forth in such plan in full.

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

c.The Servicer's acceptance of any payments 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 period plan for a modification will contain escrow amounts. If I was not previously required to pay escrow amounts, and my trial period 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 required to pay escrow amounts and my repayment plan or 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.The Servicer or authorized third party* will obtain a current credit report on all borrowers obligated on the Note.

9.The Servicer or authorized third party* will collect and record personal information that I submit in this Borrower Response Package and during the evaluation process. This personal information may include, but is not limited to: (a) my name, address, telephone number, (b) my social security number, (c) my credit score, (d) my income, and (e) my payment history and information about my account balances and activity. I understand and consent to the Servicer or authorized third party*, as well as any investor or guarantor (such as Fannie Mae or Freddie Mac), disclosing my personal information and the terms of any relief or foreclosure alternative that I receive to the following:

a.Any investor, insurer, guarantor, or servicer that owns, insures, guarantees, or services my first lien or subordinate lien (if applicable) mortgage loan(s) or any companies that perform support services to them; and

b.The U.S. Department of Treasury, Fannie Mae and Freddie Mac, in conjunction with their responsibilities under the Making Home Affordable program, or any companies that perform support services to them.

10.I consent to being contacted concerning this request for mortgage assistance at any telephone number, including mobile telephone number, or email address I have provided to the Lender/Servicer/ or authorized third party*. By checking this box

,I also consent to being contacted by text messaging.

*An authorized third party may include, but is not limited to, a counseling agency, Housing Finance Agency (HFA) or other similar entity that is assisting me in obtaining a foreclosure prevention alternative.

_______________________	__________	_______________________	__________
Borrower Signature	Date	Co-Borrower Signature	Date

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