Form

CLIENT INTAKE FORM
This form must be filled out as accurately as possible. If you have questions, you may call our office at 877-275-2423 or locally at (920) 230-3324.
What Is Your Intent To Do With The House?

KEEP SELL The property is currently listed The property is not listed DON'T KNOW
Name Of Person Filling Out This Form:
Borrower 1 Information
Borrower 1 FULL NAME:
Date Of Birth:
Gender:

MALE FEMALE
Race:
What is your level of education?
Is Borrower 1 Hispanic?

YES NO
Are you a military family on active duty?

YES NO
Employment Information - Check All That Apply

Full-Time Part-Time Unemployed W-2 Employee Self-Employed Receiving Unemployment Other
How Long At Current Employer?
Job Title:
Borrower 2 Information
Borrower 2 FULL NAME:
Date Of Birth:
Gender:

MALE FEMALE
Race:
Is Borrower 2 Hispanic?

YES NO
Employment Information - Check All That Apply

Full-Time Part-Time Unemployed W-2 Employee Self-Employed Receiving Unemployment Other
How Long At Current Employer?
Job Title:
Primary Contact Information
*Only Give Numbers Where We May Call You*
Home Phone:
Cell Phone:
Work Phone:
Email Address:
Gross Household Income Week, Month, OR Year
WEEK:
MONTH:
YEAR:
Houesehold Make-Up:
How Many Adults Live In House?
How Many Children Live In House?
When Did You Purchase The House?
Defaulted Property Address
Street Address:
City:
State:
Zip Code:
County:
Are You Living In The House?

YES NO **
** If NO, What Is Your Current Address?
Street Address:
City:
State:
Zip Code:
County:
Property Financial Information
Estimated Value Of House:
How Did You Determine the Value?

Taxes Guess Realtor Appraisal Purchase Price
Property Taxes:
Are The Taxes Current?

YES NO **
** If NO, How Delinquent?
First Mortgage Information
Mortgage Company:
Mortgage Payment:
Does Mortgage Payment include Escrow For Taxes & Insurance?

YES NO
Months Past Due:
Total Oustanding Balance Of First Mortgage:
Loan Type:

Fixed Rate Mortgage Adjustable Rate Mortgage Don't Know
If ARM, Has The Rate Adjusted?

YES NO
Current Interest Rate:
Check Those That Apply:

Interest Only Loan Pick-A-Payment FHA VA FNMA/FDMC Private Mortgage Insurance (PMI)
Second Mortgage Information
Mortgage Company:
Mortgage Payment:
Months Past Due:
Total Outstanding Balance Of Second Mortgage:
Other Information
Details of any other Mortgages Or Liens:
What Caused You To Fall Behind?
When Were You Served Court Papers?
....

I Haven't Been Served Yet.
Is A Court Date Set Yet? When?
Give Details Of Any Bankruptcy: What Type, When, and is it Active?
TODAY, Can You Afford Your Mortgage & Other Expenses?

YES NO
Have Your Ever Had A Repayment Plan?

YES ** NO
** If YES, When?
Have you worked with any other service agency regarding your foreclosure?

YES ** NO
** If YES, When?
Primary Reason For Default:
How Would You Like To Receive The Client Package?*

I Will Download It Please Email It Please Send It By Mail
Comments: Please Provide Any Additional Information You Feel Is Important For Us To Know.
How Did You Hear About HSI?

My Lender referred me for Post-Modification Counseling Foreclosure Notice In Mail Letter From HSI Radio TV Newspaper Poster/Flier Referral ** Other **
** If Referral Or Other, Please Specify:
After submitting this form, you will need to fill out our Client Package.
I have completed this form completely. All information is true and correct.*

I Agree
Should be Empty:

CLIENT INTAKE FORM

Borrower 1 Information

Borrower 2 Information

Primary Contact Information

Gross Household Income Week, Month, OR Year

Defaulted Property Address

Property Financial Information

First Mortgage Information

Second Mortgage Information

Other Information