BORRO WER F INANCIAL STA TEMEENT Loan

BORROWER FINANCIAL STATEMENT

Loan #

Borrower's Name

BORROWER

Social Security #

Home Phone #

Mailing Address

Do you occupy the property?

Yes

No

Is it a rental?

Yes

N o

Real Estate Agent's Name:

Real Estate Agent's Phone:

Have you filed

If Yes,

bankruptcy?

Yes

No

Chapter 7 Chapter 13

Employer ? Borrower

Co-Borrower's Name

CO-BORROWER

Work #

Social Security #

Home Phone #

Work #

Property Address

If so, what is the monthly rental income?

Is the property listed If so, with whom? for sale?

Yes

No

Credit Counseling Representative:

Filing Date:

Credit Counseling Rep's Phone: Attorney's Name:

Attorney's Phone:

EMPLOYMENT

How Long?

Employer ? Co-Borrower

Are there other liens on the property?

Yes

No

How Long?

Monthly Income ? Borrower

Wages

$

Unemployment Income

$

Child Support/Alimony*

$

Disability Income

$

Rents Received

$

Less: Federal & State Tax, FICA

$

Less: Other Deductions (401K, etc.)

$

TOTAL

Monthly Expense (All Borrowers)

Type

1st/2ndMortgage Other Mortgages Homeowner's Association Auto Loan #1 Auto Loan #2 Charge Cards Installment Loans Transportation (gas, bus, etc.) Car Insurance Debt Counselors Family Medical Food Utilities Cell/Phone Educational Child Care Other Other

Estimated Costs

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Confirmed Amount

$ $ $ $ $ $ $ $ $ $ $ $

TOTAL

Monthly Income ? Co-Borrower

Wages

$

Unemployment Income

$

Child Support/Alimony*

$

Disability Income

$

Rents Received

$

Less: Federal & State Tax, FICA

$

Less: Other Deductions (401K, etc.) $

TOTAL

Assets & Liabilities (All Borrowers)

Type

Checking Account(s) Savings/Money Market Stocks/Bonds/CD's IRA/Keogh Accounts 401K/ESOP Accounts Home Other Real Estate Cars Other

$ $ $ $ $ $ $ $ $ TOTAL

Estimated Value

*Notice: Alimony, child support or separate maintenance income need not be revealed if the borrower or co-borrower does not choose to have it considered for repaying this loan.

"I agree as follows: My lender may discuss, obtain and share information about my mortgage and financial situation with third parties regarding a possible alternative to foreclosure. Negotiations for a possible foreclosure alternative will not constitute a waiver of or defense to my lender's right to commence or continue any foreclosure or other collection action and an alternative to foreclosure will be provided only if an agreement has been approved in writing to my lender. The information herein is an accurate statement of my financial status. I authorize verification or re-verification of any information contained herein either directly or through a third party, including but not limited to a credit reporting agency, from any source named in this Financial Statement."

Submitted this

day of

By: Signature of Borrower

By:

Date

Signature of Co-borrower

Date

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