Open Door Counseling Center

Mortgage Default Intake Form
 
FIRST NAME :
LAST NAME :

Please use the physical address of the property in default
ADDRESS (LINE 1):
ADDRESS (LINE 2):
CITY:
STATE:
 ZIP:
DAYTIME PHONE :
 EVENING PHONE :
MOBILE PHONE :
 OTHER CONTACT:
 
EMAIL ADDRESS:
 
FAMILY SIZE :
RACE/ETHNICITY:
TOTAL HOUSEHOLD MONTHLY INCOME:
 
 
Do you want to save your home?:
 
HOW LONG HAVE YOU LIVED IN THE HOME:
HOW MANY MONTHS IN DEFAULT:
APPROXIMATE VALUE OF HOME:
HAVE YOU CONTACTED YOUR LENDER:
 IF YES, DATE CONTACTED:
HOW DID YOU HEAR ABOUT OPEN DOOR COUNSELING CENTER:
 
 
Please Describe Why You Are In Default
 
First Mortgage

Loan Number:
 
BORROWER'S FIRST NAME:
 BORROWER'S LAST NAME:
DATE OF BIRTH:
 LAST 4 DIGITS OF SOCIAL SECURITY #:
Co-BORROWER'S FIRST NAME:
 Co-BORROWER'S LAST NAME:
DATE OF BIRTH:
 LAST 4 DIGITS OF SOCIAL SECURITY #:
 
 
  NAME OF LENDER:
 LOAN TYPE:
 		LOAN AMOUNT:
  
  MORTGAGE PAYMENT:
 INTEREST RATE:
 RATE TYPE:
 IF ADJUSTABLE, INTEREST RATE CAP:
  
  IS THIS LOAN CURRENTLY IN FORECLOSURE?
IF YES, FORECLOSURE SALE DATE:
 
 
Second Mortgage

Loan Number:
 
BORROWER'S FIRST NAME:
 BORROWER'S LAST NAME:
DATE OF BIRTH:
 LAST 4 DIGITS OF SOCIAL SECURITY #:
Co-BORROWER'S FIRST NAME:
 Co-BORROWER'S LAST NAME:
DATE OF BIRTH:
 LAST 4 DIGITS OF SOCIAL SECURITY #:
 
 
  NAME OF LENDER:
 LOAN TYPE:
 LOAN AMOUNT:
  
  MORTGAGE PAYMENT:
 INTEREST RATE:
 RATE TYPE:
 IF ADJUSTABLE, INTEREST RATE CAP:
  
  IS THIS LOAN CURRENTLY IN FORECLOSURE?
IF YES, FORECLOSURE SALE DATE: