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CONTACT INFORMATION:

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Home Phone:   Work Phone:   Work Extension (If any):

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FINANCIAL INFORMATION:

* First Mortgage Lender:   * Loan Type:

* Monthly Mortgage Payment:   * # of Months Behind:

Has mortgage company returned or turned down any recent payment?

Can you afford the home if &/or when the payments are caught up?

Date Foreclosure started: (If applicable to your case) / /

Date of Foreclosure Sale: (If applicable to your case) / /

Name of Second Mortgage Lender: (If applicable to you)

2nd Mortgage Monthly Payment:   2nd Mortgage Months Behind:

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Last revision date for this form: October 4, 2006

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