Homeowners Assistance Association

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Online Application

Agent name:
First name:
Last name:
Spouses Full name:
Address:
City:
State:
Zipcode:
Phone:
eMail:
Property address:
Employer:
Years in current job:
Work phone:
Part-time employer:
Years in part-time job:
Spouses employer:
Spouse years in job:
Work phone:
Spouses part-time employer:
Spouses years in part-time job:
Number of family in household:
First mortgage lender:
Mortgage loan type:
Mortgage loan number:
Months behind:
Second mortgage lender:
Months behind:
Purchase price:
Owed/balance:
Market value/city asset:
Assets est. value/amount owned:
Cash on hand and/or obtainable (amount available for resolve):
Foreclosure lawyer:
Foreclosure date:
Notes/comments (reason for current situation):
Income
(1) Debtor's monthly take home pay:
(2) Spouses monthly take home pay:
(3) Other monthly income:
(4) Estimated avg. future monthly income:
Explanation of possible future income:
Expenses
(a) Rent or home mortgage payment:
(b) Second rent or home mortgage payment:
(c) Real estate taxes (monthly) not paid in mortgage payment:
(d) Electricity bill:
(e) Heating bill:
(f) Water/Sanitation bill:
(g) Telephone bill:
(h) Newspapers, periodicals, books:
(i) Medical and drug expenses:
(j) Auto insurance:
(k) Cable television:
(l) Transportation:
(m) Taxes(taxes not withheld from paystub):
(n) Alimony, maintenence, support:
(o) Child care, school tuition:
(p) Clothing:
(q) Laundry and cleaning:
(r) Religious/charity:
(s) Automobile payments:
(t) Monthly credit card payments:
(u) Chapter 13 payment:
(v) Food:
(w) Any miscellaneous monthly payments: