Dear Homeowner, Firstly, we would like to thank you for contacting us

Dear Homeowner,
Firstly, we would like to thank you for contacting us; we understand the burden being behind on
mortgage payments creates for you and your family. Your file will be assigned to one of our
foreclosure prevention counselors once we receive the enclosed application. We are here to help, if you
have any questions you can reach us at 843-735-7862.
So that we may serve you in a timely manner, please complete and return the enclosed documents as
soon as possible, with signature(s) where indicated. Please also be sure to include the required
supporting documents requested on the packet instruction form. Until we receive a complete packet
our counselors are unable to fully assist with lender negotiation. You may return to our attention either
by fax at (843) 735-5898 or by mail at the address at the top of this letter.
The Homeownership Resource Center, a division of Family Services, Inc., has been assisting
homeowners in the Low Country since 2003 and now serves the entire state of South Carolina. We are
a Non-Profit HUD Counseling Agency. The Homeownership Resource Center (HRC) never
charges a fee for assisting homeowners to remain in their home.
This agency would like to again thank you for the opportunity to help you save your home from
foreclosure sale. We are experienced and relentless in negotiating with a lender to modify the mortgage
payment to one that the homeowner can afford. There are numerous factors involved that determine
the ultimate outcome of negotiations with your lender and the HRC stands ready to help.
Call our office for further information at 843-735-7862 or visit our website at www.fsisc.org for
additional instruction on completing the application enclosed.
Remember NEVER pay a fee to anyone to help you negotiate a modification agreement with
your lender.
Our experienced and confident staff looks forward to working with you soon.
Sincerely,
Debbie Kidd, Director

DIRECTIONS FOR DEFAULT FORM PACKET
COST:
We do not charge any fees for our default counseling services.
FORMS:
Please fill out the following forms completely and return to The Homeownership Resource Center. Along with
your forms, please submit the following:
1) Your mortgage statement and any other correspondence from your lender or attorney
2) Two (2) pay stubs for everyone in the household along with proof of any other form of income
3) Two (2) of your most current bank statements
4) Most Recent Tax Return with W-2’s
5) Recent Utility Bill
Please be certain your name is on EVERYTHING you submit to us. All forms must be signed and all
supporting information must be received before we can begin working your case.
Questions? Call (843) 735.7862
Return completed forms and all supporting documentation to:
Via Mail or In Person: Via Fax:
The Homeownership Resource Center (843) 735-5898
Family Services, Inc. Attn: The Homeownership Resource Center
4925 Lacross Road, Suite 215
North Charleston, SC 29406
Via Email:
Scan completed documents and email to: trivers@fsisc.org
H:\Housing\default program\HRC Master Forms\DOC's\Misc Forms\Default Form Packet Directions.docx Version: March11

SUPPLEMENTAL CLIENT INFORMATION | PRE-FORECLOSURE PARTICIPANT PROFILE
Education:
(Highest Level
Completed)
Employer
Name:
How Long have you been in home? When did you start current loan?
Estimated Value of Home: Balance on Mortgage:
Interest Rate:
Fixed Rate under 8%
Fixed Rate over 8%
Adjustable Rate Mortgage under 8%
Adjustable Rate Mortgage over 8%
Have you been contacted by an attorney? YES NO
If Yes – Provide Attorney Name:
Phone Number:
Borrower
Elementary / Middle School
High School / GED
Technical Degree / Associates Degree
Bachelors Degree
Graduate School
How long have you been with this employer?
Position:
Are you self-employed? YES NO
Are you a veteran? YES NO
Household
Status:
(Check One)
Single
Female Single Parent Household
Male Single Parent Household
Married without Dependent
Married with Dependents
Two or More Unrelated Adults
Other: Check any that apply
Separated
Divorced
Widowed
Please indicate Number of Dependents in
Household: ________
Which county is the property in?
Education:
(Highest Level
Completed)
Employer
Name:
Months Past Due:
Co-Borrower
Elementary / Middle School
High School / GED
Technical Degree / Associates Degree
Bachelors Degree
Graduate School
How long have you been with this employer?
Position:
Are you self-employed? YES NO
Are you a veteran? YES NO
Household Yearly
Income Range:
(Check One)
COMPLETE ALL QUESTION ON THIS PAGE
May we contact you by phone? YES / NO Best Time to call? Best Number to call?
Household Information
Loan Information
Under $10,000
$11,000 - $15,000
$16,000 - $20,000
$21,000 - $25,000
$26,000 - $30,000
$31,000 - $35,000
$36,000 - $40,000
$41,000 - $45,000
$46,000 - $50,000
$51,000 - $55,000
$56,000 - $60,000
Over $60,000
If over $60,000, Please Indicate
Estimated Household Income:
$
Current
30 – 60 Days
61 – 90 Days
90 – 120 Days
120 + Days
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Page 1a of 3

SUPPLEMENTAL HARDSHIP AFFIDAVIT | EXPLANATION OF FINANCIAL DIFFICULTIES
Please use below space to write a brief description of financial hardship
_______________________________________________________________ _________________
Borrower (signature) Date
_______________________________________________________________ _________________
Co-Borrower (signature) Date
COMPLETE ALL QUESTIONS ON THIS PAGE
H:\Housing\default program\HRC Master Forms\DOC's\Right Side\hardship affidavit.docx Version: March11
Page 3a of 3

Dodd-Frank Certification
The following information is requested by the federal government in accordance with the Dodd-
Frank Wall Street Reform and Consumer Protection Act (Pub. L. 111-203). You are required
to furnish this information. The law provides that no person shall be eligible to receive
assistance from the Making Home Affordable Program, authorized under the Emergency
Economic Stabilization Act of 2008 (12 U.S.C. 5201 et seq.), or any other mortgage assistance
program authorized or funded by that Act, if such person, in connection with a mortgage or real
estate transaction, has been convicted, within the last 10 years, of any one of the following: (A)
felony larceny, theft, fraud or forgery, (B) money laundering or (C) tax evasion.
Borrower Co-Borrower
I have not been convicted within the last
10 years of any one of the following in
connection with a mortgage or real
estate transaction:
(a) felony larceny, theft, fraud or forgery,
(b) money laundering or
(c) tax evasion
I have not been convicted within the last
10 years of any one of the following in
connection with a mortgage or real
estate transaction:
(a) felony larceny, theft, fraud or forgery,
(b) money laundering or
(c) tax evasion
In making this certification, I/we certify under penalty of perjury that all of the information in this
document is truthful and that I/we understand that the Servicer, the U.S. Department of the
Treasury, or their agents may investigate the accuracy of my statements by performing routine
background checks, including automated searches of federal, state and county databases, to
confirm that I/we have not been convicted of such crimes. I/we also understand that knowingly
submitting false information may violate Federal law.
______________________________________ ___________
Borrower Signature Date
______________________________________ ___________
Co-Borrower Signature Date

AUTHORIZATION TO RELEASE INFORMATION
To: _____________________________________________________________________
RE: Account Number: ______________________________________________________
(To be completed by staff)
Borrower’s Name: _________________________________________________________
Address: _________________________________________________________________
_________________________________________________________________________
Dear Sir or Madam:
I am currently working with The Homeownership Resource Center, a division of Family
Services, Inc. I herby authorize you to release any and all information concerning my
financial information, verbally, written and otherwise, to Family Services, Inc at the
counselors’ request.
• I give Family Services, Inc., permission to share my personal & financial
information with outside resources that the counselor feels would be helpful in
saving my home from foreclosure. (i.e. – lenders, investors, realtors and/or credit
counselors.) I understand that I am not obligated to use any of the services offered
to me.
• I understand that Family Services, Inc. is a HUD-approved non-profit agency and,
as such, may be required to provide upon request personal and financial
information related to my case to outside agencies. (i.e. – HUD, NeighborWorks®
America, National Foreclosure Mitigation Counseling Program and other grantors.)
• I give permission for NFMC program administrators and/or evaluators to follow-up
with me for up to three (3) years from the date of this signed form for the purposes
of program evaluation.
Sincerely,
_____________________________ __________________________ _____________
Sign name here Print name here Last 4 of Social
________________________________ ____________________________ ______________
Sign name here (co-applicant) Print name here (co-applicant) Last 4 of Social
Date: ___________________________
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AUTHORIZATION TO RELEASE INFORMATION
To: _____________________________________________________________________
RE: Account Number: ______________________________________________________
(To be completed by staff)
Borrower’s Name: _________________________________________________________
Address: _________________________________________________________________
_________________________________________________________________________
Dear Sir or Madam:
I am currently working with The Homeownership Resource Center, a division of Family
Services, Inc. I herby authorize you to release any and all information concerning my
financial information, verbally, written and otherwise, to Family Services, Inc at the
counselors’ request.
• I give Family Services, Inc., permission to share my personal & financial
information with outside resources that the counselor feels would be helpful in
saving my home from foreclosure. (i.e. – lenders, investors, realtors and/or credit
counselors.) I understand that I am not obligated to use any of the services offered
to me.
• I understand that Family Services, Inc. is a HUD-approved non-profit agency and,
as such, may be required to provide upon request personal and financial
information related to my case to outside agencies. (i.e. – HUD, NeighborWorks®
America, National Foreclosure Mitigation Counseling Program and other grantors.)
• I give permission for NFMC program administrators and/or evaluators to follow-up
with me for up to three (3) years from the date of this signed form for the purposes
of program evaluation.
Sincerely,
_____________________________ __________________________ _____________
Sign name here Print name here Last 4 of Social
________________________________ ____________________________ ______________
Sign name here (co-applicant) Print name here (co-applicant) Last 4 of Social
Date: ___________________________
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FOR OFFICE USE ONLY: Counselor: ____________________________________________ No. _________________
MORTGAGE DEFAULT AND FORECLOSURE COUNSELING
CONTRACT, AUTHORIZATIONS AND DISCLOSURES
CONTRACT START DATE: ___________________________________________________________________ (Note: Contract valid for 1 year from start date)
CANCELLATION
You may cancel this contract without penalty or obligation for any reason and at any time by giving ten (10) day’s written notice of rescission to Family Services, Inc.
PAYMENTS
Family Services, Inc. cannot predict what, if any, your payment arrangement will be with your mortgage lender. With your permission we will negotiate with your mortgage lender and hope to achieve a
positive outcome that you will be able to afford. We can never guarantee that we will be able to help your situation. Family Services, Inc. and our counselors do not charge a fee to you for foreclosure
counseling services.
DESCRIPTION OF SERVICES
Family Services, Inc. will work with you to prepare a budget and the results of that budget, and your specific mortgage issues, will determine what action your counselor will recommend. Your
counselor will explain the various options that he or she thinks might work for your situation. With your permission, your counselor will negotiate with your mortgage lender if that is a feasible option
for your situation. We can never guarantee that we will be able to help your situation.
All contracts are valid for one year from the start date as listed above. All negotiations depend on you providing requested information and on your mortgage lender responding. Some lenders are 5 to 6
months behind in reviewing modification packages. After one year, the contract may be extended upon consent of both parties.
DISCLOSURES
• Credit counseling services are not suitable for all consumers and you may request information about other ways, including bankruptcy, to deal with indebtedness.
• We, Family Services, Inc. may receive grant funds from various sources for providing foreclosure prevention counseling services to you.
• We cannot require a voluntary contribution from you for a service provided by us to you.
• If you have any complaints about the credit counseling services received you may contact the South Carolina Department of Consumer Affairs at 1-800-922-1594 or 803-734-4200
• You are in no way obligated to receive any other services offered by Family Services, Inc. or any of our service providers or partners.
AUTHORIZATION TO ACCESS CREDIT REPORT INFORMATION
I/We hereby authorize Consumer Credit Counseling Services (CCCS), a division of Family Services, Inc., to access my/our credit information stored at one or more credit repositories. I fully
understand the following:
• This will appear on my credit bureau report as an inquiry.
• The Credit Bureau Repositories will NOT allow a copy of this report to be given to me personally, but I/we may request a free copy from the repositories.
• CCCS does not guarantee the accuracy of the information reported on the credit report nor the analysis done by the counselor.
• I/We agree that any disputes regarding the accuracy or completeness of said information will be directed to the source Repository (Transunion, Experian, Equifax).
• I/We give permission for NFMC program administrators and/or evaluators to follow-up with me for up to three (3) years from the date of this signed form for the purposes of program
evaluation.
FRAUD POLICY
Family Services, Inc. (the Company) is committed to preventing, identifying, and reporting any fraudulent activity related to the Company’s services, activities and administration of grants. Fraud may
include but is not limited to false statements provided by or to staff, contractors, clients, beneficiaries and stakeholders. Fraudulent activities may include but are not limited to knowingly
misrepresenting income or expenses, assisting or counseling anyone to misrepresent facts or circumstances related to eligibility for programs or benefits, bribery, kickbacks, theft or embezzlement,
forgery or alteration of documents, destruction or concealment of records, profiting from insider knowledge, or a conflict of interest. The Company will investigate any reports of fraud. The Company
reserves the right to involve law enforcement authorities in its investigation. Any documented fraudulent activity may result in administrative or criminal action being taken against those involved
including termination from any program sponsored by the Company or termination from employment by the Company. The Company will not retaliate against any party who reports fraud, criminal
activities or other program irregularities. Any suspected fraudulent activity should be reported to the Company’s currently appointed Risk Manager with sufficient specificity to facilitate an
investigation.
PRIVACY POLICY
Our agency is committed to assuring the privacy of individuals and/or families who have contacted us for assistance. We realize that the concerns you bring us are highly personal in nature. We assure
you that all information shared both orally and in writing will be managed within legal and ethical considerations. The following are examples of how this data may be used:
ALL CLIENTS
1. To assist us in our work with you, our staff may seek supervision/consultation with professional colleagues within the agency and, where appropriate and necessary, with other resources in
the community.
2. For the purpose of evaluating our services, gathering valuable research information and designing future programs, we may report case file information to various grantors and stakeholders.
COUNSELING ONLY
3. For counseling only clients, we will confirm with your creditors if asked:
a. Verification of appointment
b. Date of counseling
c. Disposition: i.e.,
1) Client will handle affairs on their own
2) Pending action
MORTGAGE DEFAULT/DEBT MANAGEMENT
4. For clients needing our intervention on your behalf through Mortgage Default or Debt Management, we will disclose the following information to your lender/creditors:
• Your address and home phone number, if published
• Total debt information
• Income, net and gross
• Living expenses
• A list of your creditors
• Personal information concerning your financial circumstances, but not lifestyle or personal habits
• Place of employment will be verified only
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MORTGAGE DEFAULT AND FORECLOSURE COUNSELING
CONTRACT, AUTHORIZATIONS AND DISCLOSURES – PAGE 2
5. We collect nonpublic personal information about you from the following sources:
• Information we received from you on our applications or other forms you provide
• Information about your transactions with us, your creditors, or others, and
• Information we receive from a credit reporting agency
In all other situations, your information may be released to appropriate individuals or agencies ONLY UPON YOUR SIGNATURE BELOW PERMITTING US TO DO SO, OR when our staff has
been served by a valid subpoena.
The following PRIVACY POLICIES detail circumstances under which we will release your information to a third party:
6. We may disclose some or all of the information that we collect, as described below, to creditors, or third parties who need this information in order for us to assist you after a counseling
session. Information includes but is not limited to:
• Information we receive from your applications or other forms, such as your name, address, social security number, assets, and income
• Information about your transactions with us, your creditors, or others, such as your account balance, payment history, parties to transactions and credit card usage
• Information we receive from a credit reporting agency, such as your credit history
7. We may disclose all of the information that we collect, as described above, to creditors and related financial institutions who need this information in order to put you on a debt management
plan (DMP) or mortgage workout.
8. We restrict access to nonpublic personal information about you to those employees who need to know that information to provide services to you. We maintain physical, electronic, and
procedural safeguards that comply with federal regulations to guard your nonpublic personal information. However, several of our grantors require that we provide some nonpublic
information about you in order to provide proof of counseling services provided and outcomes achieved.
9. Unless earlier revoked by client, this authorization will expire one year from the date signed. However, I/We give permission for NFMC program administrators and/or evaluators to
follow-up with me for up to three (3) years from the date of this signed form for the purposes of program evaluation. Additionally, I/We give permission to FSI, their grantors/stakeholders
and their representative agents to follow-up with me as necessary for purposes of program compliance and/or evaluation.
By signing below, I/we agree that I/we have read and understand the Family Services, Inc. Privacy Policy and understand my nonpublic information may be released to appropriate
individuals or agencies as necessary to assist me.
AFFILIATED BUSINESS ARRANGEMENT DISCLOSURE
Complete Action Real Estate Services, Inc. (CARES Real Estate Sales) is a for-profit wholly owned subsidiary of Family Services, Inc. Additionally, Family Services, Inc., a non-profit 501(c)(3)
organization, has several non profit divisions doing business as Consumer Credit Counseling Services (CCCS), Homeownership Resource Center (HRC), Behavioral Health Services (BHS), Financial
Management Services, (FMS), Representative Payee Services (Rep Payee) and Conservator Services. CARES Real Estate Sales provides real estate brokerage services for which it and its licensed real
estate agents typically earn a commission. Family Services, Inc. provides various counseling, granting, lending and educational services for free or for cost of service fees.
Set forth below is the estimated charge or range of charges for the settlement services listed. Family Services, Inc. will NOT require you to use the services of CARES Real Estate Sales or any affiliates
as a condition for its services.
CARES Real Estate Sales will NOT require you to use the services of Family Services, Inc. as a condition of its brokerage services. THERE ARE FREQUENTLY OTHER SETTLEMENT
SERVICE PROVIDERS AVAILABLE WITH SIMILAR SERVICES. YOU ARE FREE TO SHOP AROUND TO DETERMINE THAT YOU ARE RECEIVING THE BEST SERVICES
AND THE BEST RATE FOR THESE SERVICES.
Provider Settlement Service Charge or Range of Charges
Family Services, Inc., CCCS, HRC, BHS, FMS, Rep Payee,
Conservator
Credit and Financial Counseling
Homebuyer Education and Counseling
Grant and Loan Application Assistance
Neighborhood Revitalization LLC Development Buyer’s purchase price
Free to $150 or monthly $30
Free to $150
$990 or less, depending on grant or loan program
CARES Real Estate Sales Real Estate Brokerage Real Estate Sales Commission and/or Fees
By signing below, I/we agree that I/we have read the Affiliated Business Arrangement Disclosure, and understand that if CARES Real Estate Sales is referring me/us to Family Services, Inc.
and/or if Family Services, Inc. is referring me/us to CARES Real Estate Sales to purchase the above-described settlement service(s) and they may receive a financial or other benefit as the
result of this referral.
The Affiliated Business Arrangement Disclosure portion of this form is prepared and provided in compliance RESPA Section 8(c)(4). If you have questions or concerns you may direct them to: Caprice
Atterbury, Family Services, Inc. 4925 Lacross Rd. #215, N. Charleston, SC, 29406 Phone: 843 735 7808.
Should you decide to pursue the option of selling your home, Family Services, Inc. does not recommend or intend to influence your choice of service providers. You may choose any service
provider you want to use and in no way will your choice affect the services provided to you by Family Services, Inc.
By signing below, I/we agree that I/we have read, understand and agree to all contract provisions, authorizations and disclosures listed above (page 1 and page 2).
Client Signature:___________________________________________________________________________________ Date:_____________________________________
Client Signature:___________________________________________________________________________________ Date:_____________________________________
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attachment B
LEGAL SERVICES INCOME CERTIFICATION, DECLARATION OF CITIZENSHIP
AND REFERRAL AUTHORIZATION
NAME: DATE:
(Please Print)
INCOME CERTIFICATION
I HEREBY CERTIFY that the information I have given about my income and assets is
correct. I further consent to release of information required or requested by funders of
__________________________________.
legal services provider
________________________________________
Signature
DECLARATION OF CITIZENSHIP
I HEREBY DECLARE, that I am a citizen of the United States of America.
________________________________________
Signature
AUTHORIZATION TO REFER TO PRO BONO OR PAI
I HEREBY AUTHORIZE ________________________________________________ to
refer my case to the Pro Bono Program or the Private Attorney Involvement (PAI) Program,
when appropriate, and to send any documents and records related to my case to either.
________________________________________
Signature
CONSENT TO POSSIBLE LIMITATION OF SERVICE
I UNDERSTAND, AND AGREE, that this intake may be denied or accepted for counsel
and advice or brief service.
________________________________________
Signature
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Attachment A
WAIVER / RELEASE
for National Foreclosure Mitigation Counseling
Legal Assistance Program
I understand that under the terms of the National Foreclosure Mitigation Grant funded by NeighborWorks, the
U. S. Department of Housing and Urban Development (“HUD”) and/or other funding sources, Family Services, Inc.
(“FSI”) may refer me to an attorney for legal advice and counseling regarding my current mortgage situation. I
understand that FSI will pay for only the first five hours of counseling and legal services to be provided to me by an
attorney to whom I may be referred. If I desire additional legal services or representation beyond that initial five hour
period, it will be my sole responsibility to contract for those services with an attorney of my choice which may include the
attorney to whom I am referred by FSI.
I acknowledge that FSI is not responsible for any advice or any aspect of the legal services to be provided by any
attorney to whom I may be referred. In consideration of FSI funding the initial five hours of legal services to be provided
to me, I release FSI and all other grant funding sources, from any liability whatsoever which might arise from the
provision of those legal services to me.
I understand and agree that FSI cannot pay for legal services related to any civil litigation arising from my
mortgage situation including any foreclosure proceedings. If, during the provision of legal services by any
attorney to whom I am referred, a law suit is initiated against me or my attorney recommends that I initiate a law
suit, the services funded by FSI will terminate. I further understand and agree that if civil litigation occurs,
neither I nor the attorney to whom I am referred will be required to continue the client/attorney relationship. It
shall be my sole responsibility to arrange for further representation during any civil litigation.
I hereby give FSI permission to share my personal and financial information with
___________________________(_______). I understand and agree that Family Services, Inc., NeighborWorks, the U. S.
Department of Housing and Urban Development (HUD) and/or other funders may review my mortgage counseling case
file as a component of their monitoring of __________________ for the legal counseling services provision in
accordance with the Grant and federal regulations under which this service is provided. I hereby authorize allow
representatives of FSI, NeighborWorks, HUD and/or other funding sources to review my file for program compliance.
Borrower’s Name: __________________________________________________
Borrower’s Address__________________________________________________
__________________________________________________________________
__________________________________________________________________
Borrower’s Signature: ________________________________________________
Date: _____________________________________________
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The Homeownership Resource Center
a division of Family Services, Inc.
4925 Lacross Road - Suite 215, N. Charleston, SC 29406
Telephone: (843) 744-1348 ext. 25 or 800-232-6489 ext. 25
General Information Worksheet
Last Name First Middle/Maiden Date of Birth Social Security Number
Spouse Last Name First Middle/Maiden Date of Birth Social Security Number
Address No. / Street City, State, Zip Code County
Referred by: Race: Residence Telephone
Email Cell Phone
Gross Income:
Gross Income:
How often do you receive a paycheck?
Every Week
Every Two Weeks
Two Times a Month (i.e. on the 15th and the 30th)
Once a Month
Complete as much information as possible. Please print.
PERSONAL INFORMATION
INCOME PER PAY PERIOD (ONE PAY CHECK) - BORROWER
Every Week
Every Two Weeks
Two Times a Month (i.e. on the 15th and the 30th)
Once a Month
Employer:________________________________________
Position/Rank:____________________________________
Telephone:_____________________________ Ext:______
Total Net Income:
INCOME PER PAY PERIOD (ONE PAY CHECK) - CO-BORROWER
Employer:________________________________________
Position/Rank:____________________________________
Telephone:_____________________________ Ext:______
Total Net Income:
OTHER INCOME
Notes: Total: $0
Source Amount
Total Gross Income
Total Net Income
Total Income
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Client Name: _________________________________
Instructions: Fill in your estimated monthly expenses in the column marked "estimate". For your expenses,
use recent monthly bills to average your expenses.
Monthly Living Expenses
Fixed Expenses
ESTIMATE
Vehicle Information
Rent or Mortgage Payment $
$ $ $
Second Mortgage $
$ $ $ Make Year
Real Estate Taxes
Homeowner Insurance
only fill in if not
included in mtg
payment $
$ $ $
Homeowners Association Fee $
$ $ $ Model
Car Payment #1 $
$ $ $
Car Payment #2
$
$ $ $
Child Support Paid $
$ $ $ Condition: Good Fair Poor
Childcare
Total Fixed Expenses
$
$ $ $
Flexible Expenses
Yes No
Groceries / Toiletries $
$ $ $
Electricity /Natural Gas $
$ $ $
Trash/Sewage/Garbage $
$ $ $
Water $
$ $ $ Make Year
Home Telephone $
$ $ $
Cell Phone $
$ $ $ Model
Gasoline $
$ $ $
Medical / Dental $
$ $ $
Prescription Medication $
$ $ $ Condition: Good Fair Poor
Cable TV/Internet
$
$ $ $
Other Expenses
Total Flexible Expenses
$
$ $ $
Yes No
Periodic Expenses Dependents
Life Insurance (If not taken from pay) $
$ $ $
Health Insurance (if not taken from pay) $
$ $ $
Auto Insurance $
$ $ $
Total Expenses
Total Periodic Expenses
List current balances and account numbers for all debts. If you need additional space, please use a separate sheet.
Credit Card Debt
Creditor
Creditor
Balance
Balance
Client Signature Date
Monthly Payment
Pay Day Lenders/Cash Advance /Title Loan/Other
Monthly Payment
Current Y/N
Current Y/N
Section Totals
Add all income and subtract all judgements,
garnishments and expenses to come to a
total monthly overage or shortage.
Monthly Take Home
Income (pg1)
Monthly Living
Expenses (pg2)
Total Credit
Expenses
Total Over (+) or
Short (-)
Counselor Signature Date

Form 4506T-EZ
(October 2009)
Department of the Treasury
Internal Revenue Service
Short Form Request for Individual Tax Return Transcript
Request may not be processed if the form is incomplete or illegible.
Tip: Use Form 4506T-EZ to order a 1040 series tax return transcript free of charge.
OMB No. 1545-2154
1a Name shown on tax return. If a joint return, enter the name shown first. 1b First social security number on tax return
2a If a joint return, enter spouse’s name shown on tax return. 2b Second social security number if joint tax return
3 Current name, address (including apt., room, or suite no.), city, state, and ZIP code
4 Previous address shown on the last return filed if different from line 3
5 If the transcript is to be mailed to a third party (such as a mortgage company), enter the third party’s name, address, and telephone number. The
IRS has no control over what the third party does with the tax information.
Third party name Telephone number
Address (including apt., room, or suite no.), city, state, and ZIP code
6 Year(s) requested. Enter the year(s) of the return transcript you are requesting (for example, “2008”). Most requests will be processed within
10 business days.
Caution. If the transcript is being mailed to a third party, ensure that you have filled in line 6 before signing. Sign and date the form once you have
filled in line 6. Completing these steps helps to protect your privacy.
Note. If the IRS is unable to locate a return that matches the taxpayer identity information provided above, or if IRS records indicate that the return has
not been filed, the IRS may notify you or the third party that it was unable to locate a return, or that a return was not filed, whichever is applicable.
Signature of taxpayer(s). I declare that I am either the taxpayer whose name is shown on line 1a or 2a. If the request applies to a joint return, either
husband or wife must sign.
Note. This form must be received within 60 days of signature date.
Sign
Here
Signature (see instructions) Date
Spouse’s signature Date
Telephone number of
taxpayer on line 1a or 2a
For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 54185S Form 4506T-EZ (10-2009)

Form 4506T-EZ (10-2009) Page 2
Purpose of form. Individuals can use Form
4506T-EZ to request a tax return transcript
that includes most lines of the original tax
return. The tax return transcript will not
show payments, penalty assessments, or
adjustments made to the originally filed
return. You can also designate a third party
(such as a mortgage company) to receive a
transcript on line 5. Form 4506T-EZ cannot
be used by taxpayers who file Form 1040
based on a fiscal tax year (that is, a tax
year beginning in one calendar year and
ending in the following year). Taxpayers
using a fiscal tax year must file Form
4506-T, Request for Transcript of Tax
Return, to request a return transcript.
Use Form 4506-T to request the following.
● A transcript of a business return
(including estate and trust returns).
● An account transcript (contains
information on the financial status of the
account, such as payments made on the
account, penalty assessments, and
adjustments made by you or the IRS after
the return was filed).
● A record of account, which is a
combination of line item information and
later adjustments to the account.
● A verification of nonfiling, which is proof
from the IRS that you did not file a return
for the year.
● A Form W-2, Form 1099 series, Form
1098 series, or Form 5498 series transcript.
Form 4506-T can also be used for
requesting tax return transcripts.
Automated transcript request. You can
call 1-800-829-1040 to order a tax return
transcript through the automated self-help
system. You cannot have a transcript sent
to a third party through the automated
system.
Where to file. Mail or fax Form 4506T-EZ
to the address below for the state you lived
in when that return was filed.
If you are requesting more than one
transcript or other product and the chart
below shows two different RAIVS teams,
send your request to the team based on
the address of your most recent return.
Where to mail . . .
If you filed an
individual return
and lived in:
Alabama, Delaware,
Florida, Georgia,
North Carolina,
Rhode Island, South
Carolina, Virginia
Kentucky, Louisiana,
Mississippi,
Tennessee, Texas, a
foreign country, or
A.P.O. or F.P.O.
address
Alaska, Arizona,
California, Colorado,
District of Columbia,
Hawaii, Idaho, Iowa,
Kansas, Maine,
Maryland,
Massachusetts,
Minnesota, Montana,
New Hampshire, New
Mexico, New York,
North Dakota,
Oklahoma, Oregon,
South Dakota, Utah,
Vermont,
Washington,
Wisconsin, Wyoming
Arkansas,
Connecticut, Illinois,
Indiana, Michigan,
Missouri, New Jersey,
Ohio, Pennsylvania,
West Virginia
Mail or fax to the
“Internal Revenue
Service” at:
RAIVS Team
P.O. Box 47-421
Stop 91
Doraville, GA 30362
770-455-2335
RAIVS Team
Stop 6716 AUSC
Austin, TX 73301
512-460-2272
RAIVS Team
Stop 37106
Fresno, CA 93888
559-456-5876
RAIVS Team
Stop 6705-B41
Kansas City, MO
64999
816-292-6102
Signature and date. Form 4506T-EZ must
be signed and dated by the taxpayer listed
on line 1a or 2a. If you completed line 5
requesting the information be sent to a
third party, the IRS must receive Form
4506T-EZ within 60 days of the date signed
by the taxpayer or it will be rejected.
Transcripts of jointly filed tax returns
may be furnished to either spouse. Only
one signature is required. Sign Form
4506T-EZ exactly as your name appeared
on the original return. If you changed your
name, also sign your current name.
Privacy Act and Paperwork Reduction
Act Notice. We ask for the information on
this form to establish your right to gain
access to the requested tax information
under the Internal Revenue Code. We
need this information to properly identify
the tax information and respond to your
request. Sections 6103 and 6109 require
you to provide this information, including
your SSN. If you do not provide this
information, we may not be able to process
your request. Providing false or fraudulent
information may subject you to penalties.
Routine uses of this information include
giving it to the Department of Justice for
civil and criminal litigation, and cities,
states, and the District of Columbia for use
in administering their tax laws. We may
also disclose this information to other
countries under a tax treaty, to federal and
state agencies to enforce federal nontax
criminal laws, or to federal law enforcement
and intelligence agencies to combat
terrorism.
You are not required to provide the
information requested on a form that is
subject to the Paperwork Reduction Act
unless the form displays a valid OMB
control number. Books or records relating
to a form or its instructions must be
retained as long as their contents may
become material in the administration of
any Internal Revenue law. Generally, tax
returns and return information are
confidential, as required by section 6103.
The time needed to complete and file
Form 4506T-EZ will vary depending on
individual circumstances. The estimated
average time is: Learning about the law
or the form, 9 min.; Preparing the form,
18 min.; and Copying, assembling, and
sending the form to the IRS, 20 min.
If you have comments concerning the
accuracy of these time estimates or
suggestions for making Form 4506T-EZ
simpler, we would be happy to hear from
you. You can write to the Internal Revenue
Service, Tax Products Coordinating
Committee, SE:W:CAR:MP:T:T:SP, 1111
Constitution Ave. NW, IR-6526,
Washington, DC 20224. Do not send the
form to this address. Instead, see Where to
file on this page.

Family Services, Inc.
Customer Satisfaction Survey
Name: ____________________________________ (Optional) Date: _________________
Who was your counselor/facilitator? ___________________________________________
Service or class attended (Optional): ___________________________________________
Thank you for using Family Services, Inc.! We look forward to assisting you with your specific needs and
goals. We would like you to tell us about your initial contact with us. Please take a moment to complete this
survey and let us know how we are doing. Please place in the box located in lobby when completed. Please
circle one below. NA = Not applicable for your visit.
1. Was your counselor/facilitator knowledgeable and helpful? Yes No N/A
2. Did your session begin on time? Yes No N/A
3. Did you reach a “live person” with your initial phone call? Yes No N/A
4. Was your phone call or e-mail for an appointment returned promptly? Yes No N/A
5. Did you receive an appointment within 5 business days? Yes No N/A
6. Was the staff helpful, respectful and supportive? Yes No N/A
7. Was the receptionist friendly when you made your appointment? Yes No N/A
8. Was the receptionist friendly when you checked in? Yes No N/A
9. During your initial appt/assessment were you asked if you would like referral info? Yes No N/A
10. Did you receive a statement explaining the services offered and what is expected Yes No N/A
of you as a client?
11. Were you informed of your legal rights or privacy rights? Yes No N/A
12. Were you given information regarding your options (if applicable)? Yes No N/A
13. Is the help you are receiving in this program appropriate for your problem? Yes No N/A
14. Would you recommend Family Services, Inc. to a friend? Yes No N/A
15. Was our website helpful and informative? Yes No N/A
16. How would you rate your overall experience? (Please circle one)
Poor Fair Good Excellent Outstanding
17. How did you hear about us? (Please circle one), Name of station or show _________________________
TV Radio Newspaper Flyer Website/Online Referral from: _____________________
Your feedback is critical to the success of our agency. If your experience with us was beneficial to you, please
let us know! However, if you feel otherwise, please let us know why and what you think we could have done to
better serve you.
__________________________________________________________________________________________
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