First Name


Last Name


Phone


Secondary Phone:


Email


Address


City


State/Province

30+ days late?: Are you 30 or more
days behind on your mortgage?


--None--Yes No

Hardship?: Is there a financial hardship
that is preventing you from keeping up
with your mortgage payments?

--None--Yes No

Do you want to stay in your Home?:

--None--Yes No

Could you afford your house payment
if it is reduced by 20% to 30%?:

--None--Yes No

Are you able to make a good faith
payment to your lender if an
offer is received?:

--None--Yes No

What do you pay MONTHLY in Credit Card payments?




What is your approximate TOTAL Credit Card Debt?