Please fill out this form so that we may better advise you of your options:

Full Name

Day Phone

Evening Phone

Cell Phone

Email Address

Best time and method of contact

Property Street Address	Mailing Street Address
Property Street Address Line 2 (if needed)	Mailing Street Address Line 2 (if needed)
City	City
State	State
Zip Code	Zip Code

County

Please describe what happened

Financial Information (Do not worry about exact figures)

What type of loan do you have?	How much do you owe?	How much is the house worth?
1st Mortgage Amount	1st Mortgage Mo. Payment	1st Mortgage Company
2nd Mortgage Amount	2nd Mortgage Mo. Payment	2nd Mortgage Company
Do you have an equity line of credit or any other loan attached to this property? yes no

How far behind are the payments?
1st Mortgage month(s)	2nd Mortgage month(s)	Equity Line or 3rd Mortgage month(s)

Have you received a foreclosure warning from your lender?
yes no

Have you received a Notice of Foreclosure (Lis Pendens, Summons) from the county court?
yes no

Has a Foreclosure Sale Date been set?
yes no

If "yes", what is the sale date?

Have you ever filed a bankruptcy?

If "yes", when?

Is anyone living in the house?
yes no

Does the house need repairs?
yes no

If "yes", what type of repairs?

How long have you owned the house?

Have you ever refinanced the house?
yes no

If "yes", when?

Is the house listed with a real estate agent?
yes no

If "yes", when does the listing expire?

What would you like to do with the property?