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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: ___________________________ H:\Housing\default program\HRC Master Forms\DOC's\Right Side\Authorization to Release Information.docx Version: March11
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 H:\Housing\default program\HRC Master Forms\DOC's\Right Side\Contract Authorizations and Disclosures.doc Version March11
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Page 4: SUPPLEMENTAL CLIENT INFORMATION | P
Page 8 and 9: Dodd-Frank Certification The follow
Page 12 and 13: MORTGAGE DEFAULT AND FORECLOSURE CO
Page 14 and 15: Attachment A WAIVER / RELEASE for N
Page 16 and 17: Client Name: ______________________
Page 18 and 19: Form 4506T-EZ (10-2009) Page 2 Purp

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