Leave Blank If Not Applicable

First and Last Name		E-Mail
Tel		What's the best time to call? AnytimeMorningsAfternoonsEvenings
Property Address		City
State Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Territories		Zip Code
Do you have an auction date? YesNo		Are you currently behind on your payments? YesNo
What type of loan do you have? 40 year Fixed30 year Fixed30 year Fixed Int. Only25 year Fixed20 year Fixed15 Year Fixed10 year Fixed10 year Fixed ARM10 yr Fix Int. Only ARM7 year Fixed ARM7 yr Fix Int. Only ARM5 year Fixed ARM5 yr Fix Int. Only3 year Fixed ARM3 yr Fix Int. Only ARMOther FixedOther ARM		If you refinanced, did you receive a 3-Day Right to Cancel paper at closing?  YesNo
If you refinanced, did you ever try to cancel your loan? YesNo		Is the lender listed on your closing papers the same as the lender you pay today?     YesNo
Did your lender tell you your loan was being sold?       YesNo		Do you pay your taxes and/or insurance in your monthly payment?    YesNo
Have you received your annual escrow statement each year? YesNo		If you are behind, were you told that you can get written proof of your debt obligation?  YesNo
Is either borrower receiving disability income? YesNo		Did either borrower report disability income on your  loan application? YesNo
Is either borrower receiving workmen's compensation income? YesNo		Did either borrower  report workmen's compensation income on your loan application?      YesNo
What is the lender's name for the primary mortgage?		Do you have more than one mortgage? YesNo
If you are behind, please tell us why (Select One Main Reason)? UnemploymentReduced IncomeDivorceReduced IncomeSeparationMedical BillsToo Much DebtDeath of my SpouseDeath of a family memberPayment IncreaseBusiness FailureJob RelocationIllnessDamage to PropertyMilitary ServiceIncarcerationOther   If you think you have a bad mortgage, please tell us why (Select One Main Reason)? You Were MisleadTalked into High RateTalked Into an Adjustable RateUpside DownBad Payment PlanDid Not Know You Could CancelTried To Cancel but No ResponseYou Could Never Afford the MortgageDid Know about Having to Pay TaxesDidn't Know about Having to Pay InsurancePayments Went Up Too MuchYour Estimate Wasn't Close To Final AmountYou Have A Balloon PaymentYour Principal Balance Keeps IncreasingNever Got A Copy of Your AppraisalFeel You Were Take Advantaged OfOther     Did you refinance your loan less than 3 years ago? YesNo   Did you receive your credit score results in writing? YesNo   Were you turned down for a loan modification by your existing lender? YesNo