BORROWER'S FINANCIAL STATEMENT Servicer Loan number Property Address: Is your home for sale? Yes No Agent's Name/Company Agent's Phone ( ) Borrower Name Social Security Number Mailing Address (#, Street, Apt.) Mailing Address (City, State, Zip) Total number of persons living at this address: Number of dependents at this address: Home Phone: Work Phone: Co-Borrower Name Social Security Number Mailing Address (#, Street, Apt.) Mailing Address (City, State, Zip) Total number of persons living at this address: Number of dependents at this address: Home Phone: Work Phone: Have you contacted credit counseling services? Yes No Number of cars you own? Monthly Income (Wages): $ /mo. Additional Income (not wages): $ /mo* Source *Notice: Alimony, child support or separate maintenance income do not need be stated if the Borrower or Co-Borrower does not choose to have it considered for approval of a loan workout. Asset Type Estimated Value Liability Type Home Alimony/Child Support Real Estate Checking Accounts Savings/Money Market IRA/Keough Accounts 401K/ESOP Accounts Stocks, Bonds, CD's Investments Dependent Care Rent Mortgage(s) Personal Loan(s) Medical Expenses HOA Fees/Dues Reason for delinquency: Payment/Month Balance Due I (we) agree that the financial information provided is an accurate statement of my (our) current financial status. I (we) understand and acknowledge that any action taken by the lender of my (our) mortgage loan on my (our) behalf will be made in strict reliance on the financial information provided. My (Our) signature(s) below grants the holder of my (our) mortgage the authority to confirm the information I (we) have disclosed in this financial statement, to verify that it is accurate by ordering a credit report, and to contact my real estate agent and/or credit counseling service representative (if applicable). Submitted this day of,. By: Signature of Borrower By: Signature of Co-Borrower Date: Date: Before mailing, make sure you have signed and dated the form and attached a copy of your most recent paystub and bank statements of your checking and/or savings account to it. If you are self-employed, attach a copy of your most recent Federal Tax returns.
ASSETS INCOME GROSS NET Income Source/Employer Second Income Source/Employer Retirement/Pension Child Support Social Security Food Stamps Income Income Total Monthly Income For income, take home or "net income" is most important in this section. PROPERTY PRESENT VALUE AMOUNT OWED MONTHLY PAYMENT Mortgage Second Mortgage Car Payment Second Car Payment ASSETS & LIABILITIES PRESENT VALUE AMOUNT OWED MONTHLY PAYMENT Boat Property/Land Timeshare 401(k) - 403(b) Loan INVESTMENTS PRESENT VALUE MONTHLY CONTRIBUTION 401(k) - 403(b) Savings IRA Stocks/Mutual Funds Don't forget to include your payroll deducted 401(k) - 403(b) contributions.
EXPENSES Household expenses are categorized into essential and variable. For all categories, enter the monthly amount you spend. Many of the expenses fluctuate each month and will need to be averaged. expenses may be periodic (such as insurance, vehicle registration and taxes). Calculate the annual amount and divide by 12. ESSENTIAL LIVING EXPENSES: VARIABLE EXPENSES: HOUSING Monthly Payment PERSONAL Monthly Payment Rent/Mortgage Beauty/Barber Second Mortgage HOA (Association Dues) ENTERTAINMENT Monthly Payment Property Taxes Movie/Video Homeowner's Insurance Dining Out Renter's Insurance Sports/Hobbies/Clubs/Gym Gas/Electric (Average) Vacations/travel Water/Sewer/Garbage Reading Material/Music Cable/Satellite Telephone CLOTHING Monthly Payment FOOD Monthly Payment Purchases Groceries/Household Items Laundry/Dry Cleaning At Work/School HOME CARE Monthly Payment MEDICAL Monthly Payment Maintenance/Cleaning Health Insurance (Dental/Vision) Pool Service/Gardening Prescriptions/Doctor Visits Monitored Alarm TRANSPORTATION Monthly Payment MISCELLANEOUS Monthly Payment Car Payment Gifts Second Car Payment Pet Care Gasoline Pager/Cell Phone Maintenance/Repairs Banking Fees/postage Auto Insurance Cigarettes/Alcohol Auto Registration Computer/Online Fees Tolls/Parking/Bus Religious/Charity CHILDCARE Monthly Payment Daycare/Sitting Alimony/Child Support EDUCATION Monthly Payment Tuition/Lessons Student Loans MISCELLANEOUS Monthly Payment Taxes (monthly repayment) Life Insurance Union Dues Storage Fees For yearly expenses, divide the total figure by 12 to get the monthly payment.
CURRENT DEBTS Please list all debts with balances over $100. Do not include your mortgage payment, vehicle or student loans. List these loans in the appropriate categories on the previous expense information page. Please have your current creditor statements available during your counseling session. Name of Creditor Account Number Current Balance Current Payment Interest Rate Months
VERIFICATION AUTHORIZATION I hereby authorize you to verify my past and present employment earnings records, bank accounts, stock holdings and any other asset balances that are needed to process my mortgage loan application. I further authorize you to verify any credit information, including past and present mortgage and landlord references. This will also authorize you to obtain any loan payoff information. It is understood that a photocopy of this form will also serve as authorization. The information you obtain is only to be used in the processing of my application for a mortgage loan. NOTICE TO BORROWERS: This is notice to you, as required by the Right to Financial Privacy Act of 1978, that HUD/FHA has a right of access to financial records held by financial institutions in connection with the consideration or administration of assistance to you. Financial records involving your transaction will be available to HUD/FHA without further notice or authorization but will not be disclosed or released by this institution to another government agency or department without your consent, except as required or permitted by law. Borrower Printed Name Borrower Signature Date Co-Borrower Printed Name Co-Borrower Signature Date