Debt Counseling Corp.
3033 Expressway Drive North
Hauppauge, NY 11749
Phone: 1.888.354.6332
Email info@debtcounselingcorp.org

Mortgage Delinquency and Default Counseling Intake Form

Debt Counseling Corporation is a HUD approved 501(c)(3) not for profit organization.

To provide you with the most effective and efficient service, please complete the form below as thoroughly as possible. The more complete the paperwork is filled out, the more time we can devote to addressing your current situation.

Referral Source:

Homeowner
First Name *
Last Name *
Gender
Marital Status
Street Address
City
State
Zip/Postal Code
Mailing Address (if different)
City
State
Zip/Postal Code
Date of Birth
Social Security Number
(once you have submitted this form, please call us at 1-888-354-6332 to give us this information)
Home Phone
Work Phone
Fax
Cell Phone
Email
Preferred Contact
Are you a U.S. Citizen?
Highest level of Education Completed
Country of Origin
Ethnicity
Race
Foreign Born?
Do you have a Disability?
Are you a Veteran?
Co-Homeowner
First Name
Last Name
Gender
Marital Status
Street Address
City
State
Zip/Postal Code
Date of Birth
Social Security Number
(once you have submitted this form, please call us at 1-888-354-6332 to give us this information)
Home Phone
Work Phone
Fax
Cell Phone
Email
Preferred Contact
Are you a U.S. Citizen?
Highest level of Education Completed
Country of Origin
Ethnicity
Race
Foreign Born?
Do you have a Disability?


Total number of individuals in the household
Age:    Male   Female Age:    Male   Female
Age:    Male   Female Age:    Male   Female
Age:    Male   Female Age:    Male   Female
Age:    Male   Female Age:    Male   Female


Employment
Homeowner
Employer
Employer's Address
Start Date
Yearly Salary
$
Title/Position
Paid
Paycheck Amount After Taxes
$
Co-Homeowner
Employer
Employer's Address
Start Date
Yearly Salary
$
Title/Position
Paid
Paycheck Amount After Taxes
$


Additional Income
Income Homeowner Co-Homeowner
Alimony/Child Support $ $
Social Security $ $
Rental Income $ $
Pension $ $
Foster/Adoption Subsidy $ $
Part Time Income $ $
Other $ $


Outstanding Debt
Homeowner Co-Homeowner Monthly Payment Current/Behind
Total credit card debt $ $ $ $
Total car loans $ $ $ $
Total student loans $ $ $ $
Personal loans $ $ $ $
Unpaid taxes $ $ $ $
Other $ $ $ $


Assets
Value/Amount Amount Owed
Automobile $ $
Cash (checking/savings) $ $
Retirement (401k, 403b, IRA) $ $
Boat/Motorcycle $ $
Other $ $


Mortgage Information
Mortgage Status
If behind, how many months behind?
Reason for falling behind
What year did you first purchase the home?
Purchase Price
$
If you refinanced, how many times?
Reason for refinance
Do you want to stay in your home?
Current Value
$
Property condition?


Loan Information
First Mortgage Second Mortgage Investment Property
Loan Number
Lender
Balance
Interest Rate
Monthly Payment
Term
Rate
Yearly Taxes
Yearly Insurance
Escrow(Y/N)
Homeowner Electronic Signature By clicking this box, you agree to the above mentioned terms. Your computer's IP address (54.164.198.240) will be recorded. Date
Co-Homeowner Electronic Signature By clicking this box, you agree to the above mentioned terms. Your computer's IP address (54.164.198.240) will be recorded. Date

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