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DURHAM REGIONAL FINANCIAL CENTER

MORTGAGE DEFAULT CLINIC

APPOINTMENTS -919.806.4596

FAX-919.287.2457 EMAIL-

[email protected]

APARTNERSHIPESTABLISHEDTOASSISTYOUWITH SAVING YOUR HOMEFROMFORECLOSURE.

This form allows us to collect information needed to serve you. Please provide all information requested so that we are better prepared to expedite your request for service. Please attach a copy of your driver’s license.

How did you hear about this Agency_____________________________Today’s Date_____________________________Name___________________________________Spouse/CoHabitant Name:____________________________________Address:____________________________________HomePhone:________________Cell Phone:___________________City/State/Zip________________________________________________________County_________________________SS#___________________Race_______Sex________Age_____MartialStatus:__Single__Married__Divorced__WidowedEmail:___________________________________DOB__________________Driver’s License#_______________________

Relationship Age DOB Sex Race

Others Living in Household:

Employment:

Signed________________________________________________Date____________________________________

Signed________________________________________________Date____________________________________DISCLAIMER AND LIMITATION OF LIABILITYYou understand and agree that all services included herein are provided for informational purposes only. You understand that you may turn on or off our text alerts at any time by replying to the text message “STOP”, and that any use on your part is solely at your discretion. DRFC reserves the right at any time, in its sole discretion, to refuse to include on the service or remove from the service any user as DRFC deems necessary without cause. DRFC assumes no responsibility or liability for the timeliness, deletion, mis-delivery, the suitability, functionality, availability or operation of this service, or the veracity, accuracy, currency, adequacy, completeness, or usefulness of the service. DRFC makes no warranty that (A) the service is compatible with your equipment, (B) the service will meet your requirements, (C) the service will be uninterrupted, timely, secure or error-free, or (D) the results that may be obtained from the use of the service will be true, complete, accurate or reliable. You will be solely responsible for any damage to your equipment by virtue of your use of the service. Standard text messaging rates may apply through your service provider

Co-Applicant Employer:________________________________Position:____________________________________________Address:____________________________________________City/State/Zip_______________________________________Phone:_____________________________________________Start Date:_______________________Hrs Per Wk__________Monthly Gross Income:_$_____________________Other Source of Income:_______________________________How Much Per Month:__$_________________________

Applicant Employer____________________________________Position:_____________________________________________Address:_____________________________________________ City/State/Zip________________________________________Phone:______________________________________________Start Date:__________________________Hrs. Per Wk_______Monthly Gross Income:_$_____________________Other Source of Income:________________________________How Much Per Month:_$__________________________

Client Intake Information

Durham Regional Financial CenterFinancial Empowerment Center Homeownership Center

3307 University Drive ~Durham, NC 27707 2530 Meridian Parkway ~ Durham, NC 27713919.688.3381 919.806.4596

www.drfcenter.org



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Privacy Policy

Durham Regional Financial Center (DRFC( is committed to assuring the privacy of individuals/families who have contacted us for assistance. We realize that the concerns you bring to us are highly personal in nature. We assure you that all information shared both personal information such as your total debt information, income, living expenses and personal information concerning your financial circumstances, will be proved to creditors, program monitors and others only with your authorization and signature. We may also use anonymous aggregated case file information for the purpose of evaluation of our services, gathering valuable research information and designing future programs.

Types Of Information We Gather About You Information we receive from you orally, on applications or other forms such as your name, address, social security

number, assets and income. Information about your transaction with us, your creditors, or others, such as your account balance, payment history,

parties to transactions and credit card usage. Information we receive from credit reporting agency, such as credit history.

You May Opt-Out of Certain Disclosures You have the opportunity to “opt-out” of disclosure of your nonpublic personal information to third parties (such as

your creditors) that is, direct us not to disclose. If you choose to “opt-out”, we will not be able to ask questions from your creditors. If at any time, you wish to change your decisions with regard to your “opt-out” you may call us at 919.688.3381 and do

so.

Release of Your Information to Third Parties So long as you haven’t “opt-out” we may disclose some or all of the information that we collect, as described above, to

your creditors or third parties where we have determined that would be helpful to you, would aid us in counseling you, or is a requirement of grant awards which makes our service possible.

We may also disclose any non public personal information about you or former customer to anyone as permitted by law (e.g. if we are compelled by legal process)

Within the organization, we restrict access to non public personal information about you to those employees who need to know that information to provide series to you. We maintain physical, electronic and procedural safeguards that comply with federal regulations to regard your non public personal information.

ACKNOWLEDGEMENT:_____________________________________________ __________________________________________NAME NAME

_______________________________________________ ___________________________________________SIGNATURE SIGNATURE_______________________________________________ ___________________________________________DATE DATE

1. I understand that Durham Regional Financial Center (DRFC) provides foreclosure mitigation counseling after which I will receive a written action plan consisting of recommendations for handling my finances, possibly including referrals to other housing agencies as appropriate.

2. I understand that DRFC receives Congressional funds through the National Foreclosure Mitigation counseling (NFMC) and the National Mortgage Settlement (NMS), as such, is required to share some of my personal information with the NFMC and NMS program administrators or their agents for the purposes of the program monitoring, compliance and evaluation.

3. I give permission for the NFMC and NMS program administrators and/or their agents to pull my credit report up to two additional times and to give authorization for the NFMC and NMS program administrator and/or their agents to follow-up for the purpose of program evaluation.

4. I acknowledge that I have received a copy of the DRFC’s Privacy Policy.

5. I may be referred to other housing services of the organization or another agency or agencies as appropriate that may be able to assist with particular concerns that have been identified. I understand that I am not obligated to use any of the services offered to me.

6. A counselor may answer questions and provide information, but not give legal advice. If I want legal advice, I will be referred for appropriate assistance.

7. I understand that DRFC provides information and education on numerous loan products and housing programs and I further understand that the housing counseling I receive from DRFC in no way obligates me to choose any of these particular loan products or housing programs.

Client ‘s Signature__________________________________________Date______________________

Client’s Signature___________________________________________Date______________________



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Foreclosure Mitigation Counseling Agreement



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Certification of Foreclosure Mitigation

I/We certify that I/we have not received any counseling sessions for foreclosure mitigation intervention with another counseling organization from March 1, 2008 to present. I understand that I am providing this information for the purposes of receiving counseling that is funded by NeighborWorks America and or the National Mortgage Settlement. ___________________________________________ ______________________________________________HOMEOWNER (Printed Name) HOMEOWNER (Signature)

___________________________________________ _____________________________________________HOMEOWNER (Printed Name) HOMEOWNER (Signature) DURHAM REGIONAL FINANCIAL CENTER__________ _______________________________________________ COUNSELING AGENCY DATE

DRFC COUNSELORS:

KAREN GALLOWAY TERRI LEESARAH MASON EVELYN LOUDERANTHONY ALIZIERI ANDREA ORTIZ

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 begin receiving assistance from the Makin 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, or any one of the following: (A) felony larceny, theft, fraud or forgery, (B) money laundering or (C) tax evasion.

I/We certify under penalty or perjury that I/We 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/We understand that the servicer, the U.S. Department of 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.

This Certificate is effective on the earlier of the dates listed below or the date received by your servicer.

___________________________________________ _____________________________ _________________________ _______________________Borrower Signature Social Security Number Date of Birth Date

__________________________________ ________________________ ____________________ __________________Co-Borrower Signature Social Security Number Date of Birth Date

Third-Party Authorization Form

_________________________________________ ___________________________________________Mortgage Lender/Servicer Name (“Servicer”) [Account][Loan] NumberThe undersigned Borrower and Co-Borrower (if any) (individually and collectively, “Borrower” or “I”), authorize the above Servicer and the following third parties

DURHAM REGIONAL FINANCIAL CENTER _______ __________________________________________[Counseling Agency] [Agency Contact Name and Phone Number]

NORTH CAROLINA HOUSING FINANCE AGENCY __ ___________________________________________[State HFA Entity] [State HFA Contact Name and Phone Number]________________________________________ ___________________________________________[Other Third Party] [Third Party Contact Name and Phone Number]________________________________________________________________________________________________[Relationship of Other Third Party to Borrower and Co-Borrower]

(individually and collective, “Third Party to obtain, share, release, discuss, and otherwise provide to and with each other public and non-public personal information contained in or related to the mortgage loan of the Borrower. This information may include (but is not limited to) the name, address, telephone number, social security number, credit score, credit report, income government monitoring information, loss mitigation application status, account balances, program eligibility, and payment activity of the Borrower. I also understand and consent to the disclosure of my personal information and the terms of any agreements under the Making Home Affordable or Hardest Hit Fund Programs by Servicer or State HFA to the U. S. Department of the Treasury or their agents in connection with their responsibility under the Emergency Economic Stabilization act.The Servicer will take reasonable steps to verify the indent of a Third Party, but has no responsibility or liability to verify the identity of such Third Party. The Servicer also has no responsibility or liability for what a Third Party does with such information.

This Third-Party Authorization is valid when signed by all borrowers and co-borrowers named on the mortgage and until the Servicer receives a written revocation signed by any borrower or co-borrower.

Before signing this Third-Party Authorization, beware of foreclosure rescue scams! * It is expected that a HUD-approved housing counselor, HFA representative or other authorized third party will work directly with your lender/mortgage servicer. * Please visit http://makinghomeaffordable.gov/counselor.html to verify you are working with a HUD-approved housing counseling agency.

I UNDERSTAND AND AGREE WITH THE TERMS OF THIS THIRD –PARTY AUTHORIZATION:

Borrower Co-Borrower

_______________________________________ ______________________________________Printed Name Printed Name

_______________________________________ ______________________________________Signature Signature

_______________________________________ ______________________________________Date Date

SIGN SIGN



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THIRD PARTY AUTHORIZATION and AGREEMENT to RELEASE

Loan Number:__________________________ Loan Servicer Name:_________________________________

Property Address:_________________________________________________________________________

I/we do hereby authorize _______________________________________ (my lender/mortgage servicer) to release or otherwise provide public and non-public personal financial information contained in my loan account which may include, but is not limited to, loan balances, final payoff statement, loan payment history, payment activity, and/or property information to:

DURHAM REGIONAL FINANCIAL CENTER (Company) in the capacity of:HOUSING COUNSELING AGENCY (Relationship) at :

2530 Meridian Parkway, Durham, NC 27713 Telephone: 919.806-4596.

I/we, the borrower(s) understand that lender/mortgage servicer, will take reasonable steps to verify the identify of the 3rd party authorized above, but will have not responsibility or liability to verify the true identity of the requestor when he/she asks to discuss my account or seeks information about my account. Nor shall the lender/mortgage servicer, have any responsibility or liability for what the requestor may do with the information he/she obtains concerning my account.

I/we, the borrower(s) do hereby indemnify and forever hold harmless the lender/mortgage servicer, from all action and cause of actions, suits, claims, attorney fees, or demands against the lender/service which I/we and/or my heirs may have resulting from the lender/mortgage servicer discussing my loan account and/or providing any information concerning the loan account to the above names requestor or person identifying themselves to be that requestor.

I/we the borrower(s) agree to this Authorization and the terms of the Release as stated above. All the borrower(s) have signed and dated below.

________________________________ _____________________________ _______________Printed Borrower Name Borrower’s Signature Date

________________________________ _____________________________ _______________Printed Co-Borrower Name Co-Borrower’s Signature Date

MONTHLY LIVING EXPENSES ESTIMATE OTHER

Rent or Mortgage Payment

Mortgage Paid To:

Second MortgageRenter/Homeowner Insurance

2nd Mortgage Paid To:

Car Payment #1Car Payment #2 Delinquent

Rent/Mortgage?Child Care

______Yes ______No

Child Support Type of MortgageLoan

TOTAL FIXED EXPENSES

$ $ ______Conventional______FHA______VA

Church/CharityGroceriesMeals Out/School LunchesSavingsElectricity/Oil/Gas Vehicle Information #1Water/Sewage/Garbage Make___________________

___Telephone/Mobile/Beeper

Model______________________

Family Clothing ConditionDry Cleaning/Laundry ____Good____Fair_____Po

orGasoline/Travel Vehicle Information #2School Tuition/Supplies Make___________________

___Allowances Model___________________

___Barber/Beauty Shop ConditionBooks/Newspaper ____Good____Fair_____Po

orEntertainment/GiftsMedical/Dental/MedicationCigarettes/Tobacco/AlcoholCable TV

MONTHLY LIVING EXPENSES

MiscellaneousTOTAL FLEXIBLE

EXPENSES$ $

Life Insurance TOTAL EXPENDITURESCar InsuranceHealth/Accident Insurance

Fixed:______________________

Car/Home Maintenance Flexible:___________________

Property Taxes Periodic:___________________

TOTAL PERIODIC EXPENSES

$ $ TOTAL:_______________

Additional documents could be requested based upon your specific circumstance.Additional documents could be requested based upon your specific circumstance.Additional documents could be requested based upon your specific circumstance.

Required Documents for Mortgage Loan AssistancePlease complete all sections below

Please provide copies only—keep originals for your records.Section 1: All borrowers listed on the loan must provide all of the documents

in this section.

Section 2: All borrowers listed on the loan are required to complete certain financial documents in order to request mortgage assistance.

Two most recent monthly bank statements (printed with all pages, even if the last page is blank)Federal tax return from the previous year with all schedules (all pages, signed and dated)

Copies of these documents can be downloaded at www.drfcenter.org (go to intake application tab).

Please note: if all borrowers are not attending the in-person meeting, they must complete these documents in advance.IRS Form 4506T Third Party Authorization Hardship Letter Dodd-Frank Certification

Privacy Policy Request for 30 Day Extension Foreclosure Mitigation Counseling Agreement

Certification of Foreclosure Mitigation Counseling

Section 3: In addition, all borrowers must provide the documents under each category that applies.

If you are a salaried or hourly employee:Most recent and consecutive pay stubs showing 30 days of income and year-to-date earnings (less than 60 days old)

If you are self-employed:Most recent quarterly or year-to-date profit/loss statement-signed and datedBusiness federal tax return form the previous 5 years (all pages, signed and dated)

If your home is your primary resident ( you currently live in your home):Most recent utility bill (gas, electric, water) showing your name and property addressDeed of Trust General Warrant DeedProperty Tax Bill Proof of Homeowners Insurance

If you belong to a Homeowners Association:Most recent bill or letter from Homeowners/Condominium Association reflecting amount and frequency of dues

If you had a co-borrower removed from the loan (or are currently having them removed):A quit claim deed showing that the borrower’s name has been removed for from the loan

If you receive alimony, child support or separation maintenance as qualifying income:Divorce decree, separation agreement, other written agreement filed with the court, or decree that states the amount and period of time payment will be received

If you receive income from social security, disability or death benefits, pension, adoption assistance, public assistance, unemployment or if your employment is seasonal:Benefits statement or letter from the provider that states the amount, frequency and duration of the benefitIf unemployed, proof of unemployment wages for a minimum of 3 months

If you have income from any other source(s) such as tips, commission renter income or investments:Documentation describing the nature of the income, such as an employment contract, tenant rental agreement, spouse/parental support, tips, etc.

Copies of these documents will be provided on site when you meet with your counselor:Request for Mortgage Assistance (RMA) and Uniform Borrower Assistance Form ( Form )710

Additional documents could be requested based upon your specific circumstance.

Additional documents could be requested based upon your specific circumstance.Additional documents could be requested based upon your specific circumstance.Additional documents could be requested based upon your specific circumstance.

Additional documents could be requested based upon your specific circumstance.