DURHAM REGIONAL FINANCIAL CENTER. Mortgage Default/Delinquency Program APPLICATION FOR SERVICE

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1 DURHAM REGIONAL FINANCIAL CENTER Mortgage Default/Delinquency Program APPLICATION FOR SERVICE Appointments Fax info@drfcenter.org 1

2 Prescreening Questionnaire The N.C. Foreclosure Prevention Fund helps homeowners who are struggling to pay the mortgage on their primary residence due to job loss or temporary financial hardship. It is offered by the N C. Housing Finance Agency using funds from the U. S. Treasury. Please respond to the following prescreening questions to determine possible eligibility for assistance. Prescreening Response Please provide a brief comment in addition to your response for each question 1. Are you a homeowner who has experienced a loss of job or reduction in income on or after January 1, 2008? 2. If the answer to #1 is YES, was the loss of job or reduction in income due to no fault of your own? 3. Are you currently receiving unemployment benefits or disability benefits? 4. If the answer to # 3 is NO, have you received unemployment benefits in the past. 5. If the answer to #4 is YES, please indicate the year you received the unemployment benefits 6. Do you need assistance with the mortgage on your primary residence? 7. If the answer to # 6 is YES, are you current on the mortgage? 8. If the answer to #7 is NO, please indicate the number of months you are delinquent. YES NO YES NO YES NO YES NO YR YES NO YES NO # MONTHS 9. Is the property located in North Carolina YES NO 10, Is the total amount currently owned on the property less than $300, YES NO 11. Are you currently seeking employment? YES NO 12. Are you currently enrolled in school? YES NO 13. Have you in the past 6 months received or requested a loan modification? 14. If the answer to # 13 is YES, what is the current status of your request? YES NO Pending Approved Denied 15. Are you classified as military personnel? YES NO 16. Are you currently furloughed by your employer? YES NO 2

3 Durham Regional Financial Center Financial Empowerment Center & Homeownership Center 2634 Durham-Chapel Hill Blvd ~ Suite 214 ~ Durham, NC Voice: / Fax: / Website: Client Intake Information This form allows us to collect information needed to serve you. Please provide all information requested so that we are better prepared to expedite your request for service. Please attach a copy of your driver s license. How did you hear about this Agency Today s Date Name Spouse/CoHabitant Name: Address: Home Phone: Cell Phone: City/State/Zip County SS# Race Sex Age Martial Status: Single Married Divorced Widowed DOB Driver s License# Other s Living in Household: Relationship Age DOB Sex Race Employment Applicant Employer Co-Applicant Employer Position: Position: Address: Address: City/State/Zip City/State/Zip Phone: Phone: Start Date: Hrs. Per Wk Start Date: Hrs. Per Wk Monthly Gross Income:_$ Monthly Gross Income:$ Other Source of Income: Other Sources of Income: How Much Per Month:_$ How Much Per Mth:$ 1.DISCLAIMER AND LIMITATION OF LIABILITY You understand and agree that all services included herein are provided for informational purposes only. By signing the agreement, you authorize DRFC to deliver autodialed, pre-recorded and/or text marketing messages to a designated phone number; and understand that you are not required to sign the agree-ment or agree to enter into it as a condition of purchasing any property, goods or services. You understand that you may turn on or off our text alerts at any time by replying to the text message STOP, and that any use on your part is solely at your discretion. DRFC reserves the right at any time, in its sole discre-tion, to refuse to include on the service or remove from the service any user as DRFC deems necessary without cause. DRFC assumes no responsibility or liability for the timeliness, deletion, mis-delivery, the suitability, functionality, availability or operation of this service, or the veracity, accuracy, currency, ade-quacy, completeness, or usefulness of the service. DRFC makes no warranty that (A) the service is compatible with your equipment, (B) the service will meet your requirements, (C) the service will be uninterrupted, timely, secure or error-free, or (D) the results that may be obtained from the use of the service will be true, complete, accurate or reliable. You will be solely responsible for any damage to your equipment by virtue of your use of the service. Standard text messaging rates may apply through your service provider. 2. I UNDERSTANDING THAT RECORDING OR FILMING THE SESSION OR PRESENTATION IS NOT PERMITTED Signed Date Signed Date 3

4 Durham Regional Financial Center 2634 Durham-Chapel Hill Blvd ~ Suite 214 ~ Durham, NC Voice: / Fax: Privacy Policy Durham Regional Financial Center (DRFC( is committed to assuring the privacy of individuals/families who have contacted us for assistance. We realize that the concerns you bring to us are highly personal in nature. We assure you that all information shared both personal information such as your total debt information, income, living expenses and personal information concerning your financial circumstances, will be proved to creditors, program monitors and others only with your authorization and signature. We may also use anonymous aggregated case file information for the purpose of evaluation of our services, gathering valuable research information and designing future programs. Types Of Information We Gather About You Information we receive from you orally, on applications or other forms such as your name, address, social security number, assets and income. Information about your transaction with us, your creditors, or others, such as your account balance, payment history, parties to transactions and credit card usage. Information we receive from credit reporting agency, such as credit history. You May Opt-Out of Certain Disclosures You have the opportunity to opt-out of disclosure of your nonpublic personal information to third parties (such as your creditors) that is, direct us not to disclose. If you choose to opt-out, we will not be able to ask questions from your creditors. If at any time, you wish to change your decisions with regard to your opt-out you may call us at and do so. Release of Your Information to Third Parties So long as you haven t opt-out we may disclose some or all of the information that we collect, as described above, to your creditors or third parties where we have determined that would be helpful to you, would aid us in counseling you, or is a requirement of grant awards which makes our service possible. We may also disclose any non public personal information about you or former customer to anyone as permitted by law (e.g. if we are compelled by legal process) Within the organization, we restrict access to non public personal information about you to those employees who need to know that information to provide series to you. We maintain physical, electronic and procedural safeguards that comply with federal regulations to regard your non public personal information. ACKNOWLEDGEMENT: NAME SIGNATURE DATE NAME SIGNATURE DATE 4

5 Durham Regional Financial Center 2634 Durham-Chapel Hill Blvd ~ Suite 214 ~ Durham, NC Voice: / Fax: Foreclosure Mitigation Counseling Agreement 1. I understand that Durham Regional Financial Center (DRFC) provides foreclosure mitigation counseling after which I will receive a written action plan consisting of recommendations for handling my finances, possibly including referrals to other housing agencies as appropriate. 2. I understand the DRFC receives Congressional funds through the National Foreclosure Mitigation counseling (NFMC) and, as such, is required to share some of my personal information with the NFMC program administrators or their agents for the purposes of the program monitoring, compliance and evaluation. 3. I give permission for DRFC agents to pull my credit report up to two additional times. 4. I give authorization for NFMC program administrator and/or their agents to follow-up for the purpose of program evaluation only. 5. I authorize DRFC to submit client-level information to the Data Collection System for the NFMC grant and I authorize NFMC program administrators to open files to be reviewed for program monitoring and compliance purposes. 6. I acknowledge that I have received a copy of the DRFC s Privacy Policy. 7. I may be referred to other housing services of the organization or another agency or agencies as appropriate that may be able to assist with particular concerns that have been identified. I understand that I am not obligated to use any of the services offered to me. 8. A counselor may answer questions and provide information, but not give legal advice. If I want legal advice, I will be referred for appropriate assistance. 9. I understand that DRFC provides information and education on numerous loan products and housing programs and I further understand that the housing counseling I receive from DRFC in no way obligates me to choose any of these particular loan products or housing programs. Client s Signature Date Client s Signature Date 5

6 Durham Regional Financial Center 2634 Durham-Chapel Hill Blvd ~ Suite 214 ~ Durham, NC Voice: Fax: Certification of Foreclosure Mitigation Counseling I/We certify that I/we have not received any counseling sessions for foreclosure mitigation intervention with another counseling organization from March 1, 2008 to present. I understand that I am providing this information for the purposes of receiving counseling that is funded by NeighborWorks America. HOMEOWNER (Printed Name) HOMEOWNER (Signature) HOMEOWNER (Printed Name) HOMEOWNER (Signature) DURHAM REGIONAL FINANCIAL CENTER COUNSELING AGENCY DATE DRFC COUNSELORS: CYNTHIA DUKES JOHNETTA ALSTON NATHAN FARRIOR 6

7 Durham Regional Financial Center Financial Empowerment Center & Homeownership Center 2634 Durham-Chapel Hill Blvd ~ Suite 214 ~ Durham, NC Voice: / Fax: / Website: Durham Regional Financial Center Counseling Services Disclosure Form Durham Regional Financial Center may make you aware of products and/or services that we believe offer value to our clients. These products and/or services might be available directly from Durham Regional Financial Center, lenders, developers, or other agencies with which Durham Regional Financial Center has a working relationship. You are under no obligation to use the products and/or services identified by Durham Regional Financial Center, whether by us or from industry partners. Services provided by Durham Regional Financial Center: FE: Financial Education No Charge FC: Financial Counseling $59.00 CC: Credit Counseling $59.00 CMP: Credit Monitoring Plan $ / $99.00 per mth DMP: Debt Management Program $40.00 enrollment fee TBB: The Benefit Bank Services No Charge REN: Rental Counseling $59.00 HBE: Homebuyer Education No Charge PPHC: Pre-Purchase Homeownership Counseling $59.00 PPHC: Post Purchase Homeownership Counseling $59.00 PFHC: Pre-Foreclosure Homeownership Counseling No Charge FHA: FHA Back to Work Counseling $ HECM: Reverse Mortgage Counseling $ ACA: Affordable Healthcare Enrollment No Charge Client s Printed Name: Signature: Date: / / Client s Printed Name: : Signature: Date: / / 7

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12 Financial Worksheet Gross Monthly Income #1 $ Gross Monthly Income #2 $ Other Monthly Income $ Total Household Monthly Income $ Monthly Living Expenses Estimates Actuals Other Rent or Mortgage Payment Mortgage Paid To: Second Mortgage Renter/Homeowner Insurance 2 nd Mortgage Paid To: Car Payment #1 Car Payment #2 Delinquent Rent/Mortgage? Child Care Yes No Child Support Type of Mortgage Loan Total Fixed Expenses $ $ Conventional FHA Church/Charity Groceries Meals Out/School Lunches Savings Electricity/Oil/Gas Vehicle Information #1 Water/Sewage/Garbage Make Model Telephone/Mobile/Beeper Family Clothing Dry Cleaning/Laundry Condition Good Fair Poor Gasoline/Travel Vehicle Information #2 School Tuition/Supplies Make Model Allowances Barber/Beauty Shop Condition Books/Newspaper/Entertainment/Gifts Good Fair Poor Medical/Dental/Medication Cigarettes/Tobacco/Alcohol Cable TV Miscellaneous Total Flexible Expenses $ $ Life Insurance Total Expenditures Car Insurance Health/Accident Insurance Total Fixed: $ Car/Home Maintenance Total Flexible: $ Property Taxes Total Periodic: $ Total Periodic Expenses $ $ Total: $ 12

13 Creditors Balance Owed Monthly Payment Last Payment Account Number 1st Mortgage 2nd Mortgage Other Mortgage Loan Total Mortgages $ $ Credit Card Debt Total Credit Card Debt $ $ Car/Personal Loans Total Car/ Personal Loans $ $ Medical Debt Total Medical Debt $ $ Other Debt Grand Total for All Debt $ $ 13

14 Request for 30 Day Extension Durham Regional Financial Center (DRFC) is committed to working on a plan to save your home and because your loan is part of the State Housing Foreclosure Prevention Project, we can request that the Commissioner of Banks Office grant an extension that will give you an additional 30 days to establish a remedy for your mortgage situation. This one time offer will mean that the Servicer cannot begin foreclosure proceedings for another 30 days. If the extension is granted, it can only be done once and you won t be able to request this again. Should you agree to the extension, it will only be requested if needed during the time we are working to save your home. AUTHORIZATION: I authorize DRFC to request a 30 day extension. I understand that it will only be used if needed during the time they are working to assist me. I further understand that it can only be done once. I agree to sign and return this request to Durham Regional Financial Center at 2634 Durham-Chapel Hill Blvd, Suite 214, Durham, NC or fax to I do not wish to request the 30 day extension. ACKNOWLEDGEMENT: Primary Borrower Co-Borrower Lender Date Date Loan Number 14

15 Please note: if all borrowers are not attending the in-person meeting, they must complete these documents in advance. IRS Form 4506T Third Party Authorization Hardship Letter Dodd-Frank Certification Privacy Policy Request for 30 Day Extension Foreclosure Mitigation Counseling Agreement If you are a salaried or hourly employee: Most recent and consecutive pay stubs showing 30 days of income and year-to-date earnings (less than 60 days old) If you are self-employed: 1) Most recent quarterly or year-to-date profit/loss statement-signed and dated, 2) Business federal tax return form the previous 5 years ( signed and dated) Required Documents for Mortgage Loan Assistance Please provide copies only keep originals for your records. Section 1: All borrowers listed on the loan must provide all of the documents in this section. Two most recent monthly bank statements (printed with all pages, even if the last page is blank) Federal tax return from the previous year with all schedules (all pages, signed and dated) Section 2: All borrowers listed on the loan are required to complete certain financial documents in order to request mortgage assistance. Certification of Foreclosure Mitigation Counseling Section 3: In addition, all borrowers must provide the documents under each category that applies. For questions, contact us at: or info@drfcenter.org A quit claim deed showing that the borrower s name has been removed for from the loan If you receive alimony, child support or separation maintenance as qualifying income: Divorce decree, separation agreement, other written agreement filed with the court, or decree that states the amount and period of time payment will be received If your home is your primary resident ( you currently live in your home): 1) Most recent utility bill (gas, electric, water) showing your name and property address, 2) Deed of Trust /General Warranty Deed/Property Tax Bill/ Proof of Homeowners Insurance If you belong to a Homeowners Association: Most recent bill or letter from Homeowners/ Condominium Association reflecting amount and frequency of dues If you had a co-borrower removed from the loan (or are currently having them removed): If you receive income from social security, disability or death benefits, pension, adoption assistance, public assistance, unemployment or if your employment is seasonal: Benefits statement or letter from the provider that states the amount, frequency and duration of the benefit If unemployed, proof of unemployment wages for a minimum of 3 months If you have income from any other source(s) such as tips, commission renter income or investments: Documentation describing the nature of the income, such as an employment contract, tenant rental agreement, spouse/parental support, tips, etc. 15