Wells Fargo Home Preservation Documents Download

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Homeowner Assistance Form
Page 1 of 5
Homeowner Assistance Form
Mortgage loan number:
I/We want to: Keep the property Sell the property
The property is my/our: Primary residence Second home Investment property
The property is: Owner occupied Renter occupied Vacant
Borrower Co-borrower
Borrower’s name
Co-borrower’s name
Social Security number
Date of birth Social Security number Date of birth
Home phone number
( )
Home phone number
( )
Cell phone number
( )
Cell phone number
( )
Work phone number
( )
Work phone number
( )
Email address
Email address
Mailing address
Mailing address (if different than borrower’s)
Property information
Property address (if same as mailing address, write “same”)
Number of people who live in the home
Is this property listed for sale? Yes If yes, what was property listing date? No
Have you received an offer on the property? Yes Date of offer ____________ Amount of offer $ No
Agent/agency name
Agent/agency phone number ( )
For sale by owner? Yes No
Who pays the real estate tax bill on your property?
I/We do Servicer does
Are the taxes current? Yes No
Condominium or homeowners association fee? Yes $ No
Paid to (Name & address)
Who pays the homeowners insurance policy for your property?
I/We do Servicer does Paid by condominium or homeowners association
Is the policy current? Yes Name of insurance company No
Insurance company phone number ( )
If there are additional liens/mortgages or judgments on this property, name the person(s), company or firm and phone
Lien holder's name/Servicer________________ Phone number ( )__________ Loan number ___________ Balance $___________
Lien holder's name/Servicer________________ Phone number ( )__________ Loan number ___________ Balance $___________
Borrower/co-borrower situation
Have you contacted a credit-counseling agency for help? Yes No
If yes, complete counselor contact information below.
Counselor’s name _____________________________ Counselor’s phone number ( ) ___________________________
Counselor’s email _____________________________
Homeowner Assistance Form
Page 2 of 5
Have you filed for bankruptcy? Yes No
If yes: Chapter 7 Chapter 11 Chapter 12 Chapter 13 Filing date_____________________________
Has your bankruptcy been discharged? Yes No Bankruptcy case number ___________________
Please note that if you have or will receive a discharge from a chapter 7 bankruptcy case, and the mortgage was not reaffirmed in the bankruptcy
case, we will only exercise our rights against the property and are not attempting any act to collect the discharged debt from you personally.
Additionally, your decision to discuss workout options with us is strictly voluntary. You are not obligated to pursue any workout options
discussed with us. At your request, we will immediately terminate any such discussions should you no longer wish to pursue these options.
Hardship Affidavit (Provide a written explanation with this request describing the specific nature of your hardship.)
I/We am/are requesting review of my/our current financial situation to determine whether I/we qualify for temporary or permanent mortgage
relief options.
Date hardship began is: _________________
I believe that my/our situation is:
Short-term (under 6 months)
Medium-term (6-12 months)
Long-term or Permanent Hardship (greater than 12 months)
I/we am/are having difficulty making my/our monthly payment because of reasons set forth below:
(Please check all that apply and submit required documentation demonstrating your hardship)
If your hardship is: Then the required hardship documentation is:
Unemployment No hardship documentation required
No hardship documentation required, as long as you have submitted income
documentation that supports the income described in the required income
documentation section
Income reduction (e.g., elimination of
overtime, reduction in regular working hours,
or a reduction in base pay)
No hardship documentation required, as long as you have submitted income
documentation that supports the income described in the required income
documentation section
Divorce or legal separation; Separation of
Borrowers unrelated by marriage, civil union
or similar domestic partnership under
applicable law
Divorce decree signed by the court; OR
Separation agreement signed by the court; OR
Current credit report evidencing divorce, separation, or non-occupying
borrower has a different address; OR
Recorded quitclaim deed evidencing that the non-occupying Borrower or Coborrower has relinquished all rights to the property
Death of borrower or death of either the
primary or secondary wage earner in the
Death certificate; OR
Obituary or newspaper article reporting the death
Long-term or permanent disability; Serious
illness of a borrower/co-borrower or dependent
family member
Doctor’s certificate of illness or disability; OR
Medical bills; OR
Proof of monthly insurance benefits or government assistance (if applicable)
Disaster (natural or man-made) adversely
impacting the property or Borrower’s place of
Insurance claim; OR
Federal Emergency Management Agency grant or Small Business
Administration loan; OR
Borrower or Employer property located in a federally declared disaster area
Distant employment transfer No hardship documentation required
Business failure
Tax return from the previous year (including all schedules) AND
Proof of business failure supported by one of the following:
• Bankruptcy filing for the business; OR
• Two months recent bank statements for the business account evidencing
cessation of business activity; OR
• Most recent signed and dated quarterly or year-to-date profit and loss
Homeowner Assistance Form
Page 3 of 5
Income/expenses for household
Important note: All income must be documented.
Include combined income and expenses from the borrower and co-borrower (if any). If you will be including income and expenses from a
household member who is not a borrower, please specify on the back of this form. Also, include the non-borrower(s) start date(s) employment
information. You are not required to disclose child support, alimony or separation maintenance income unless you choose to have it considered
by your servicer.
1 2 3
Monthly household income Monthly household expenses/debt Household assets
Monthly gross wages $ First mortgage payment $ Checking account(s) $
Overtime $
Second mortgage payment/
other liens
$ $
Borrower start date of
employment (MMDDYYYY)
Homeowners insurance1 $
Savings/money market
Co-borrower start of
employment (MMDDYYYY)
Property taxes2 $ $
Borrower other employment
state date (MMDDYYYY) (if
borrower has a second job)
Credit cards/installment
loan(s) (total minimum
payment per month)
Certificate(s) of deposit
Co-borrower other
employment start date
maintenance/child support
$ $
Child support/alimony/
separation maintenance
Net rental expenses/
property maintenance
$ $
Non-taxable Social
Security/Social Security
Disability Insurance
Homeowners association/
condominium fees
$ Stocks/bond(s) $
Taxable Social Security
$ Child care expenses $ $
Other monthly income from
pensions, annuities or
retirement plans
Car payments, including car
lease payments
$ Other cash on hand $
Tips, commissions and bonus
Car insurance/gas/
Other real estate (estimated
Self-employment $
Health insurance/medical
$ Other $
Unemployment income $
Life insurance premiums
(not withheld from pay)
$ $
Start date of unemployment
Groceries $ $
Rent received $ Water/sewer/utilities $ $
Boarder income $
phone/home phone
Do not include retirement plans when
calculating assets (401(k), pension funds,
annuities, IRAs, Keogh plans, etc.)
Food stamps/Welfare $ Personal loans/tuition $
Other (investment income,
royalties, interest, dividends,
Other $
Total (gross income) $ Total debts/expenses $ Total assets $
1. Only include your homeowners insurance payment if you pay this amount yourself.
2. Only include your property ax payments if you pay them yourself.
Homeowner Assistance Form
Page 4 of 5
Acknowledgment and Agreement
I/We understand that I/we will be considered for all mortgage assistance options available to us, including federal government programs as
appropriate. I/We certify as follows:
1. That all of the information in this affidavit is true and accurate and the event(s) identified on page two is/are the reason that I/we need to
request a modification of the terms of my/our mortgage, short sale or deed in lieu of foreclosure.
2. I/We understand that the Servicer, the U.S. Department of the Treasury, or its agents may investigate the accuracy of my/our statements, may
require me/us to provide supporting documentation, and that knowingly submitting false information may violate federal law and may result
in foreclosure.
3. I/We understand the Servicer may pull a current credit report on all borrowers obligated on the Note.
4. I/We understand that if I/we have intentionally defaulted on my/our existing mortgage, engaged in fraud or misrepresented any fact(s) in
connection with this document, the Servicer may cancel any Agreement and may pursue foreclosure on my/our home and/or pursue any
available legal remedies.
5. I/We understand, to be considered for certain federal government programs my/our property must be owner-occupied. If I/we have not
indicated otherwise on this form, I/we certify that: my/our property is owner-occupied and I/we intend to reside in this property for the next
twelve months and I/we have not received a condemnation notice and there has been no change in the ownership of the property since
I/we signed the documents for the mortgage that I/we want to modify.
6. I/We am/are willing to provide all requested documents and to respond to all Servicer questions in a timely manner.
7. I/We understand that the Servicer will use the information in this document to evaluate my/our eligibility for a loan modification or short sale
or deed in lieu of foreclosure, but the servicer is not obligated to offer me/us assistance based solely on the statements in this document.
8. I/We am/are willing to commit to credit counseling if it is determined that my/our financial hardship is related to excessive debt.
9. If I/we am/are eligible for a trial period plan, repayment plan, or forbearance plan, and I/we accept and agree to all terms of such plan, I/we
also agree that the terms of this Acknowledgment and Agreement are incorporated into such plan by reference as if set forth in such plan in
full. My/Our first timely payment following my/our Servicer’s determination and notification of my/our eligibility or prequalification for a trial
period plan, repayment plan, or forbearance plan (when applicable) will serve as acceptance of the terms set forth in the notice sent to me that
sets forth the terms and conditions of the trial period plan, repayment plan, or forbearance plan.
10. I/We agree that when the Servicer accepts and posts a payment during the term of any repayment plan, trial period plan, or forbearance plan
it will be without prejudice to, and will not be deemed a waiver of, the acceleration of my/our loan or foreclosure action and related activities and
shall not constitute a cure of my/our default under my/our loan unless such payments are sufficient to completely cure my/our entire default
under my/our loan.
11. I/We agree that any prior waiver as to my/our payment of escrow items to the Servicer in connection with my/our loan has been revoked.
12. If I/we qualify for and enter into a repayment plan, forbearance plan, and trial period plan, I/we agree to the establishment of an escrow
account if an escrow account never existed on my/our loan as required.
13. I/We understand that the Servicer will collect and record personal information, including, but not limited to, my/our name(s), address,
telephone number, Social Security number(s), credit score, income, payment history, government monitoring information, and information
about account balances and activity. I/We understand and consent to the disclosure of my/our personal information to (a) the U.S. Department
of the Treasury or its agents; (b) any investor, insurer, guarantor or Servicer that owns, insures, guarantees or services my/our first lien or
subordinate lien (if applicable) mortgage loan(s); (c) companies and/or individuals that perform support services in conjunction with home
preservation mortgage assistance efforts; (d) auditors, including but not limited to independent auditors, regulators and agencies; and (e) any
HUD-certified housing counselor.
14. I/We consent to being contacted concerning this request for mortgage assistance at any cellular or mobile telephone number I/we have
provided to the Servicer. This includes text messages and telephone calls to my/our cellular or mobile telephone.
Please note: this letter is being sent in response to your request for assistance. In order to assist you with this request, we must be able to contact
you. Therefore, any previous request to cease communication with you as been waived for these purposes. If this is incorrect, please contact us
(Borrower) (Date) (Co-borrower) (Date)
Homeowner Assistance Form
Page 5 of 5
Contacts — if you have questions
If you have questions about this document or your available options, please contact your home preservation specialist.
If you have questions about your options that your Servicer cannot answer or if you need further counseling, call the Homeowner’s HOPE™
Hotline at 1-888-995-HOPE (4673). A Hotline counselor will help you by answering questions about your available options and providing you
with free HUD-certified counseling services in English and Spanish.
Notice to Borrower
Be advised that you are signing this document under penalty of perjury. Any misstatement of material fact made in the
completion of these documents including but not limited to misstatement regarding your occupancy in your home, hardship
circumstances, and/or income will subject you to potential criminal investigation and prosecution for the following crimes:
perjury, false statements, mail fraud, and wire fraud. The information contained in these documents is subject to examination
and verification. Any potential misrepresentation will be referred to the appropriate law enforcement authority for investigation
and prosecution.
By signing the enclosed document you certify, represent and agree that: “Under penalty of perjury, all documents and information
I have provided to Servicer in connection with this Agreement, including the documents and information regarding my eligibility
for mortgage assistance, are true and correct.”
If you are aware of fraud, waste, abuse, mismanagement or misrepresentations affiliated with the Troubled Asset Relief Program,
please contact the SIGTARP Hotline by calling 1-877-SIG-2009 (toll-free), 202-622-4559 (fax), or www.sigtarp.gov. Mail can
be sent to Hotline Office of the Special Inspector General for Troubled Asset Relief Program, 1801 L St. NW, Washington, DC

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