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

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: _____________________________________________
H:\Housing\default program\HRC Master Forms\DOC's\Right Side\CLIENT Waiver Release.doc Version: March11