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

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
H:\Housing\default program\HRC Master Forms\DOC's\Right Side\profile supplement.docx Version: March11
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