BORROWER ACKNOWLEDGEMENT FORM

Transcription

1 /302/ AMBER L STIERLEY S Sherman Lake Dr Augusta MI BORROWER ACKNOWLEDGEMENT FORM You must sign and return this form to the address listed in order to participate in the loan rehabilitation program. Failure to agree to the capitalization of collection costs renders you ineligible for participation in this program. By signing below, I understand and agree that the lender may capitalize collection costs of 18.5% of the outstanding principal and accrued interest upon rehabilitation of my loan(s). I also understand and agree that the lender may capitalize any outstanding accrued interest at the time of Rehabilitation. Signature: Date: Printed Name: Signed Name: Social Security Number: Telephone Number: Regional Adjustment Bureau, Inc Charles Bryan Rd Suite 110 Memphis TN rehab@rabinc.com This is an attempt to collect a debt and any information obtained will be used for that purpose. This communication is from a debt collector. This collection agency is licensed by the Tennessee Collection Service Board of the Department of Commerce and Insurance.

2 Si usted prefiere un representante español, llame al (877) Account Number: Client: Michigan Guaranty Agency (MGA) LOAN REHABILITATION PROGRAM TERMS FORM Congratulations! You are eligible to participate in the Loan Rehabilitation Program. You can receive many benefits from this program, which are outlined for you below. This form is the first step to enter into Loan Rehabilitation and confirms our agreement to accept reasonable and affordable monthly payments of in conjunction with your request to participate. We encourage you to participate in the program and take advantage of this opportunity, and we are providing you with the following terms and conditions. Nine (9) qualifying payments within a ten (10) month period of, with a due date of, must be received timely. To be considered timely, each payment must be received no earlier than 20 days before your due date and no later than 20 days after your due date. According to federal law, a loan may be considered for rehabilitation only after you have made voluntary reasonable and affordable full payments for each of the 9 qualifying payments within a 10 month period. If a payment is received too late, too early, or for less than the agreed amount, this offer becomes null and void and the series of payments must start over again. After you have made the voluntary reasonable and affordable payments, the loan(s) maybe considered for purchase by an eligible lender to complete the Loan Rehabilitation. You must continue to make your monthly payments, as agreed upon, until you are notified that your loan(s) have been rehabilitated. Once your loan(s) is rehabilitated and is no longer in default, the national credit bureaus will be notified to delete the derogatory credit rating previously reported by the guarantor in reference to the loan(s). Once rehabilitation is complete, collection costs that have been added will be reduced to 18.5% of the unpaid principal and accrued interest outstanding at the time of Loan Rehabilitation. Collection costs may be capitalized at the time of the Loan Rehabilitation by your new lender, ALONG WITH OUTSTANDING ACCRUED INTEREST, to form one new principal amount. Once your loan(s) are rehabilitated, you can apply for additional financial aid if you return to school. You also regain remaining deferment and forbearance eligibility on the rehabilitated loan(s). You may object to the rehabilitation terms outlined in this form by contacting Regional Adjustment Bureau, Inc. at To participate in the Loan Rehabilitation program and take advantage of the benefits above we MUST RECEIVE THE ATTACHED ACKNOWLEDGEMENT FORM BACK, WITH YOUR SIGNED APPROVAL. Once we receive the form with your signature, and you have made your monthly payments, your loan(s) will be considered for Loan Rehabilitation. If the loan(s) is rehabilitated, we will notify you once the Loan Rehabilitation is complete. The lender will establish a new repayment schedule after rehabilitation and your monthly payments may increase or decrease according to the new schedule. This is an attempt to collect a debt and any information obtained will be used for that purpose. This communication is from a debt collector. RONRABI02335 Regional Adjustment Bureau, Inc Charles Bryan Rd, Suite 110 PO Box Memphis TN (866) (901) Office Hours: 8:00 AM - 9:00 PM Monday-Thursday, 8:00 AM - 6:00 PM Friday

3 APPLICATON FOR REASONABLE AND AFFORDABLE PAYMENTS NOTE: BEFORE YOU COMPLETE THIS FORM, PLEASE REVIEW THE ATTACHED INSTRUCTIONS CAREFULLY. PRINT OR TYPE NEATLY. I AN ITEM DOES NOT APPLY TO YOU WHEN YOU ARE COMPLETING THIS FORM, ENTER N/A (NOT APPLICABLE). (1) NAME: (LAST, FIRST, MIDDLE) (2) SOCIAL SECURITY NUMBER: (3) PERMANENT STREET ADDRESS: (3) CITY: (3) STATE: (3) ZIP: (4) HOME TELEPHONE: (5) WORK TELEPHONE: (6) DATE OF BIRTH: (7) DRIVERS LICENSE NUMBER: State # (8) DO YOU RENT OR OWN YOUR RESIDENCE: (8) LANDLORD/MORTGAGE COMPANY: (8) HOW LONG HAVE YOU LIVED HERE: RENT OWN (9) VEHICLES: (ATTACH LIST IF NECESSARY) YR. MAKE MODEL YR. MAKE MODEL (10) MARITAL STATUS: (11) LIST DEPENDENTS AND AGES: EMPLOYMENT INFORMATION (Documentation required) (12) EMPLOYER NAME: (13) JOB DESCRIPTION: (14) STREET ADDRESS: (14) CITY (14) STATE: (14) ZIP: (15) DATE OF EMPLOYMENT: / / CHILD SUPPORT: HOUSE: ALIMONY: OTHER REAL ESTATE: (16) GROSS MONTHLY INCOME: INTEREST INCOME: CHECKING: PENSIONS: SAVINGS: (17) NET MONTHLY INCOME: OTHER INCOME DISABILITY: ASSETS STOCKS/BONDS: SOCIAL SECURITY: DEBTS BALANCE MONTHLY FINANCIAL INFORMATION MORTGAGE/RENT CHILD SUPPORT ALIMONY CREDIT CARDS OTHER STUDENT LOANS UTILITIES PHONE CAR PAYMENT CABLE TELEVISION INSURANCE HEALTH LIFE AUTOMOBILE GROCERIES PUBLIC TRANSPORTATION CAR FUEL MEDICAL COSTS DEPENDENT CARE INHERITANCE: (18) DID YOU FILE A TAX RETURN LAST YEAR? YES NO (Documentation required) AFDC OR ADC: WORKMAN S COMP: PERSONAL PROPERTY: CHECKING ACCOUNT NAME: INFORMATION: ADDRESS: STATE: ZIP: ACCOUNT NUMBER: BALANCE: SAVINGS ACCOUNT NAME: INFORMATION: ADDRESS: STATE: ZIP: OTHER: OTHER: ACCOUNT NUMBER: BALANCE: PLEASE PROVIDE OTHER INFORMATION THAT MAY BE PERTINENT WITH ANY DOCUMENTATION THAT YOU BELIEVE IS NECESSARY. OTHER TOTAL Documentation Checklist Written Request: Proof of Income Recommendation YES SIGNATURE DATE FOR INTERNAL USE ONLY Reason for NGS recommendation: Date NO Signature

4 Item 1: Item 2: Item 3: INSTRUCTIONS FOR COMPLETING APPLICATION FOR REASONABLE AND AFFORDABLE PAYMENTS Enter your last name, then your first name and middle name Enter your nine-digit Social Security Number. Enter your permanent home address, apartment number, city, state and zip code. Item 4: Enter your area code and telephone number for the address listed in Item 3. Item 5: Item 6: Item 7: Item 8: Item 9: Item 10: Item 11: Enter the telephone number of the place where you are employed. Enter the month, day and year of your birth. (Use numbers only. Be careful not to enter the current year) Enter your driver s license number. (List the state that issued the license followed by the number) Check next to the appropriate selection. Enter the name of your landlord or mortgage company. Enter the number of years in which you have lived at the address listed in Item 3. (If you have lived there less than a year, list the number of months) Enter the year, make, model, and tag number of the vehicles that you own. (If you own more than two vehicles, attach a separate list describing these vehicles) Enter your marital status. Enter the names of your dependents and their ages. (Attach a separate list for additional dependents) EMPLOYMENT INFORMATION (Attach Separate List If Necessary) Item 12: Item 13: Item 14: Enter the name of the business that employs you. Enter your job title or description of your duties. Enter your work address. Item 15: Enter the month, day and year of your employment at the business entered in Item 12. Item 16: Enter your monthly income before required deductions have been made. (Documentation required) Item 17: Enter your monthly income before required deductions have been made. (The amount deducted for insurance should be included in the section entitled DEBTS.) Item 18: Check the appropriate box. (Attached documentation of your federal and state tax returns if you filed a tax return last year) OTHER INCOME: Enter the monthly amount of any other income that you receive. (Documentation required) ASSETS: Enter the value of any assets that you may have. Items that must be include in personal property include televisions, video equipment, stereos, and other items. DEBTS, BALANCE AND MONTHLY PAYMENT: Enter the balance owed and the monthly payment on each debt listed. If you have other debts that are not listed, enter the source of debt, the balance of the debt and the monthly payment. FINANCIAL INFORMATION: Enter the name and address of the financial institution(s) where you checking and/or savings accounts are located. Include the account number and current balance. Attach a separate list of other institutions if necessary. OTHER INFORMATION: A space has been provided for you to enter information that you believe is pertinent regarding your situation. SIGNATURE AND DATE: This form must be signed and dated. You signature certifies that the information that you have provided is true and accurate.

5 Automated Withdrawal Authorization Thank you for your interest in participating in our Automatic payment system. RAB Account Number Printed Full Name Address City, State, Zip Telephone Number By list any cellular telephone number I authorize Regional Adjustment Bureau (RAB) to contact me regarding my account at the cellular telephone number provided by using a predictive or automated telephone dialing system and/or artificial or pre recorded voice messages. Financial Institution's Name Financial Institution's City & State Checking Routing Number Bank Account Number Credit Card Visa Mastercard Credit Card # Cardholder Name Experation Date Payment Amount CVV (3 digit # on back of card) How often should this amount be withdrawn? Weekly Bi weekly Monthly (Same date each Month) Start Date Due Date Comments: I (we) authorize Regional Adjustment Bureau (RAB) to initiate charges to my checking or shard draft account described above. This authorization will remain in effect until RAB has received a written notification to terminate the agreement within a reasonable time frame to act on it. I will contact RAB if there are any changes to my bank account information. Bank Account Holder Signature Bank Account Holder Signature (If joint accounts, both must sign) Date Return Authorization Form & Voided Check to: Regional Adjustment Bureau, Inc Charles Bryan Rd Suite 110 Memphis, TN Fax: ach@rabinc.com This is an attempt by a debt collector to collect a debt. Any information obtained will be used for that purpose.

6 The following information may pertain for your state of residence: This collection agency is licensed by the Tennessee Collection Service Board of the Department of Commerce and Insurance. California As required by law you are hereby notified that a negative credit report reflecting on your credit record may be submitted to a credit reporting agency if you fail to fulfill the terms of your credit obligations. The state Rosenthal Fair Debt Collection Practices Act and the federal Fair Debt Collection Practices Act require that, except under unusual circumstances, collectors may not contact you before 8 a.m. or after 9 p.m. They may not harass you by using threats of violence or arrest or by using obscene language. Collectors may not use false or misleading statements or call you at work if they know or have reason to know that you may not receive personal calls at work. For the most part, collectors may not tell another person, other than your attorney or spouse, about your debt. Collectors may contact another person to confirm your location or enforce a judgment. For more information about debt collection activities, you may contact the Federal Trade Commission at FTC HELP or Nonprofit credit counseling services may be available in the area. Colorado A consumer has the right to request in writing that a debt collector or collection agency cease further communication with the consumer. A written request to cease communication will not prohibit the debt collector or collection agency from taking any other action authorized by law to collect the debt. FOR INFORMATION ABOUT THE COLORADO FAIR DEBT COLLECTION PRACTICES ACT, SEE Our local office address is 3025 S. Parker Rd., #711, Aurora, CO Our local phone number is Massachusetts NOTICE OF IMPORTANT RIGHTS YOU HAVE THE RIGHT TO MAKE A WRITTEN OR ORAL REQUEST THAT TELEPHONE CALLS REGARDING YOUR DEBT NOT BE MADE TO YOU AT YOUR PLACE OF EMPLOYMENT. ANY SUCH ORAL REQUEST WILL BE VALID FOR ONLY TEN DAYS UNLESS YOU PROVIDE WRITTEN CONFIRMATION OF THE REQUEST POSTMARKED OR DELIVERED WITHIN SEVEN DAYS OF SUCH REQUEST. YOU MAY TERMINATE THIS REQUEST BY WRITING TO THE DEBT COLLECTOR. Minnesota This collection agency is licensed by the Minnesota Department of Commerce. North Carolina North Carolina Department of Insurance permit number New York New York City Dept of Consumer Affairs Permit No Wisconsin This collection agency is licensed by the Office of the Administrator of the Division of Banking, P.O. Box 7876, Madison, Wisconsin Washington This collection agency is licensed in the State of Washington at the following address: 1900 Charles Bryan, Suite 110 Memphis, TN Utah As required by Utah law you are hereby notified that a negative credit report reflecting on your credit record may be submitted to a credit reporting agency if you fail to fulfill the terms of your credit obligations.