Mortgage Assessment

Contact Information
First Name		Last Name
Middle Initial		Age
Sex	Select Male Female No Answer	Marital Status	Select Single Married Divorced Domestic Partnership
Street Address 1		Street Address 2
City		State
Zip Code
Home Phone		Alternate Phone
E-Mail Address

Tell us about your mortgage

How much did you originally pay for your home?
What year did you buy your home?
How much did you put down at the time of purchase?
What is the balance due on your 1st mortgage?
If you have a second or third mortgage, what are the balances?	Second Third
Have you been threatened with foreclosure?	Select Yes No
Are you the person solely responsible for payment?	Select I am solely responsible Myself & my spouse are responsible I am a co-signer I have a co-signer who is not related I have a co-signer who is related
What is the past due amount on your first mortgage?
If you have a 2nd or 3rd mortgage, what are the past due amounts?	Second Third
What is the fair market value of your home?
What is the amount of your monthly mortgage payment?
What is the current interest rate on your mortgage?
If your rate fixed or adjustable?	Select Fixed rate 3 year adjustable 5 year adjustable Option-ARM Interest Only Reverse Interest
Describe your home	Select Single Family Condo Multi-Family 2-4 Units Multi-Family 4 or more units Co-Op Apartment

General Information

Employment Status	Select Un-employed Retired Disability Income Self-employed Employed-1099 Employed-W2
Have you experienced any of the following in the last 12 months? (check all that apply)	Illness Loss of job Family Death Divorce Substance Abuse
	Other

Do you have any other special circumstances we should know about?

Payment Information

Billing Information
Name (As it appears on credit card) *
Type of card *	Visa Master Card Discover
Card Number *
Expiration Date *
Security Code *