Homeowner Listing Acknowledgement

Transcription

Homeowner Listing Acknowledgement
Emerald City Realty is a New York State licensed Real Estate Broker, located at 200 Old Country Rd., Mineola, NY,
11501. The Broker of Record is George Gavalas. If throughout the process of selling your home you have any
questions or concerns please contact Mr. Gavalas directly at 631.913.4100. Please thoroughly read and review the
information below and initial each paragraph to confirm your complete understanding, acknowledgement and
consent.
[ ] The sale of your home is subject to your lender(s) accepting a reduced payoff or a “Short Sale”.
[ ] You have been provided with the form titled "Short Sale Addendum to Exclusive Listing Agreement". This form
contains important information about your listing transaction. By initialing here you confirm that you have read, fully
understand, agree with and have executed the form.
[ ] Emerald City Realty uses the services of Short Sale Homes and/or Pullin Law Firm to negotiate the short payoff(s)
required to complete the sale of your home. Emerald City Realty is a wholly owned subsidiary of Short Sale Homes.
[ ] You have been provided with the following forms:
[
[
[
[
] Listing Agreement for Real Property Exclusive Right to Sell
] New York State Disclosure Form for Buyer and Seller
] Lead Based Paint AND/OR lead Based Paint Hazards Disclosure
] Sellers Obligations Regarding Property condition Disclosure
These forms contain important Information about your listing transaction. By initialing above you confirm that you
have received, read, fully understand, agree with, consent and executed the forms.
[ ] ln addition to providing negotiation services Short Sale Homes and/or Emerald City Realty may earn an additional
Buyer Broker Fee which may be paid outside of closing in connection with the sale of your home.
[ ] As per your listing agreement your home may be placed on the local multiple listing service. The public listing will
contain the following language In the remarks section. Please review below and by initialing this paragraph you
confer and consent to the conditions set forth.
"Short Sale Subject to Third Party Bank Approval. Provided the listing is active, the company will continue to accept
"Qualified Offers" regardless of the listing status, which will be presented to the seller up until 3 days prior to the
closing, Qualified offers for this property is defined as follows; Buyers whose offers are all cash and not subject to
financing must provide acceptable proof of funds sufficient to complete the purchase dated within 15 days of the offer.
For buyers whose offer is subject to financing an acceptable pre-approval must be provided. Listing broker reserves
the right to require any buyer to be pre-qualified by a lender of his choice. Property sold AS-IS. All offers including
the required documentation above should be sent to offers@emeraldcityhomesales.com."
offers@emeraldcityrealty.com."
Property Address: Street____________________________ City____________________ State _____ ZIP_______
Homeowner Print Name _______________________________________________________
Homeowner Sign _____________________________________________________________ Dated___/___/____
Homeowner Print Name _______________________________________________________
Homeowner Sign _____________________________________________________________ Dated___/___/____
FOR OFFICE USE ONLY
Listing Agent Acknowledgement: I hereby confirm that I have provided this acknowledgment to the homeowner
witnessed its signature and have truthfully answered any questions asked by the homeowner.
Listing Agent Signature________________________ Dated___/___/____ License Number ____________________
RESIDENTIAL PROPERTY DATA SECTION (PDS)
LONG ISLAND
MULTIPLE
LISTING
SERVICE
REALTORS
EQUAL OPPORTUNITY
LENDER
*
*Broker Load (Y or N)
Means Required Information
Street #:
Street Dir:
LOCATION
PRICE &
DATES
St Suffix:
*Zone:
Sec/Area:
*Zip:
Zip + 4:
Cross St:
*School District Name:
School District #:
District:
Lot:
Section:
Block:
Zoning:
*Waterfront (Y or N):
Water Frontage:
Bulkhead (Y or N):
Docking Rights:
Cul-de-sac (Y or N):
Waterfront Desc.:
Beach Rights (Y or N):
*Listing Price:
*Taxes (w/o exempt.):
*Listing Date:
*Waterview (Y or N):
*Adult Community (Y or N):
Min Age:
Additional Village Taxes:
*Exp Date:
*Style:
*Rooms:
*# Families:
HOME CHARACTERISTICS
*ML #
*Street Name:
*Town:
*Detached/Att (Det-Att-Sd):
*Dining Room:
*Bedrooms:
*# Kitchens:
*Den/Family Rm (Y or N):
*Baths-Full:
*Baths-Half:
*Eat In Kitchen (Y or N):
*Office (Y or N):
*
Attic (Y or N)
Handicap Access (Y or N):
Handicap Access Desc.:
Approx int Square Footage:
*# Fireplaces:
*Basement (Crawl-Full-Part-None-Opt):
W/W Carpet (Y or N):
Floor Description:
Bsmt/Subfloor:
*1st Floor:
2nd Floor:
3rd Floor:
Skylight:
Wood Floors: (Y or N):
Garage:
Deck:
*Approx. Year Built:
Garage Type:
Patio:
*Pool (AG-IG-N):
Finished Bsmt (P-Y-N):
*New Construction: (Y or N):
Appearance:
*Construction:
EXTERIOR
Y
Driveway (PTY-PVT-N):
Porch:
Pool Desc.:
Inground Lawn Sprinklers:
Tennis Court (Y or N):
*Lot Size:
Tennis Court Desc.:
*Lot Sq. Footage:
UTILITIES
APPLIANCES
Building Size:
*Stove:
*Refrigerator:
*Fuel:
*A/C (# or CAC):
*Washer:
*Heat:
CAC # Zones
RESIDENTIAL PROPERTY DATA - 6R REV. 03/2007
*Dryer:
*Dishwasher:
# Heating Zones:
Sewer (Y or N):
Separate Hot Water Heater:
Water (Public-Well):
Subsidiary of Long Island Board of Realtors, Inc.
Page 1 of 4
This contract is for use by Americas Real Estate Advisors. Use by any other party is illegal and voids the
contract.
RESIDENTIAL PROPERTY DATA SECTION (PDS)
LONG ISLAND
MULTIPLE
LISTING
SERVICE
REALTORS
EQUAL OPPORTUNITY
LENDER
OWNER/BROKER
*
Means Required Information
*Owner:
Y
*ML #
*Phone #:
*Seller Agency Compensation:
*Buyer Agency Compensation:
*Broker Agency Compensation:
Agency (Enter A If Agency):
* Exclusions(Yor N):
*Negotiate Direct (Yor N):
Occupancy:
Show Instructions:
Lockbox (Y or N):
Remarks:
REMARKS
*Broker Load (Y or N)
Owner Financing (Y or N)
Short sale subject to 3rd party approval. Property sold AS-IS. Cash
buyers must provide proof of funds. Finance buyers must provide proof
of funds. Send all offers to offers@areaagent.com.
*Directions:
Property
Desc.:
MISCELLANEOUS
(No Contact
info, Status,
etc.)
Rent Income:
*Also For Rent (Y or N):
Renting Broker Compensation:
Items Excluded In Sale:
*Supersedes (Y or N):
Supersedes ML #:
Broker Open House Start Date:
OPEN
HOUSE
Rental Price:
Broker Open House Time:
Consumer Open House Start Date:
Consumer Open House Time:
Foreclosure (Y or N):
Broker Open House End Date:
Broker Open House Note:
Consumer Open House End Date:
Consumer Open House Note:
SIGNATURES
Owner Signature _________________________________________ Owner Signature _________________________________________
Address ________________________________________________ Email Address ___________________________________________
Home Phone ____________________________________________ Other Phone ____________________________________________
Americas Real Estate Advisors
Date ___________________________________________________ MLS Office Name _________________________________________
Ruben Rodriguez
Co-Listing Agent _________________________________________
Listing Agent ____________________________________________
RESIDENTIAL PROPERTY DATA - 6R REV. 03/2007
Page 2 of 4
contract.
ML#___________________________
Property Address__________________________________________________________________________
List Price_______________________________________
LISTING AGREEMENT FOR REAL PROPERTY
EXCLUSIVE RIGHT TO SELL
Commission Rates for the Sale, Lease or Management of Property Shall be Negotiated between the BROKER1 and the Owner
EMPLOYMENT
1. The BROKER agrees to act as a special limited agent for the Owner(s) for the sole purpose of finding a Purchaser and/or Tenant to buy and/or rent the property described in
the PROPERTY DATA SECTION hereinafter called PDS at the price and conditions set in the PDS. The PDS is incorporated herein by reference.
2. The parties agree that the BROKER represents the owner as seller's agent and shall cooperate with other licensed real estate brokers who are Participants in the Multiple Listing
Service of Long Island, Inc. (MLSLI) (Cooperating Brokers). The owner acknowledges the BROKER must cooperate with agents who represent buyers. Such buyer's agents
represent the interests of the prospective buyers only. In addition to cooperating with buyer's agents the owner authorizes the BROKER to work with seller's agents and/or
broker's agents as indicated by the compensation offered in paragraph 6. The compensation to be paid to a cooperating broker representing a buyer should be inserted in
paragraph 6 of this agreement.
3. The Owner(s) authorizes the BROKER to enter the information set forth in the PDS, and any photographs, images, graphics and video recordings of the owner's property
whether taken by BROKER'S agent, supplied by owner or otherwise (listing content), into a listing content compilation owned by MLSLI. The Owner understands and agrees
that said compilation is exclusively owned by MLSLI who alone possesses the right to publish said compilation in any media form it deems appropriate including, the World
Wide Web. MLSLI may license, sell, lease and commercially utilize its compilation. Among other uses MLSLI may license or sell the listing content to aggregators who will
aggregate the listing content and resell the same. Such aggregated content shall not contain any personal information about the owner other than the owner's name. If any
photograph, image, graphics or video recordings were created by the owner and are delivered to BROKER for use in the MLSLI compilation by virtue of such delivery and
the execution of this agreement the owner(s) hereby irrevocably assign and Transfers to BROKER any and all copyright rights and other intellectual property rights in the
foregoing.
4. BROKER agrees to use its experience and knowledge to determine the appropriate marketing plan for the property. The Owner(s) grants to the BROKER full discretion to
determine an appropriate marketing plan for the property.
5. The owner shall not offer nor show their property for sale or rent to any prospective buyers or tenants but shall refer all such prospective buyers or tenants to the BROKER,
nor shall the owner negotiate the sale or rental of the property with a buyer unless the BROKER participates in such negotiations.
COMPENSATION
6
6. A. The Owner(s) hereby agrees to pay the BROKER a total commission in the amount of __________%
of the selling price Or $_____________ or in the case of a rental
by separate agreement. Said commission shall be shared with Cooperating Brokers as follows:
1
If the Cooperating Broker is a Seller's Agent __________%
of the selling price Or $_____________.
1
If the Cooperating Broker is a Broker's Agent __________%
1
If the Cooperating Broker is a Buyer's Agent __________%
B.Said total commission shall be earned and payable under any of the following conditions:
(a) If the BROKER or Cooperating Broker produces a buyer ready, willing and able to purchase the property on the terms and conditions set forth in the PDS;
(b) If through the BROKER's or Cooperating Broker's efforts a buyer and the owner(s) reach an agreement upon all the essential terms of a transaction.
(c) If the property is sold or rented during the term of this Agreement whether or not the sale or rental is a result of the BROKER'S efforts and even if the property is sold as a
result of the efforts of the Owner(s) or any other broker or agent not acting under this agreement.
(d) If the BROKER or Cooperating Broker is the procuring cause of a transaction.
7. The above compensation shall be paid to the BROKER in the event that the owner enters into a contract of sale to sell the property or actually sells the property within a period
120
of ___________
days after the termination of the agreement to any person (buyer) who has been shown the property during the term of this agreement. This paragraph shall
not apply if the Owner(s) has in good faith relisted the property with another broker after the expiration of this Agreement and prior to the commencement of negotiations with
such buyer.
GOOD FAITH
8. In the event the Owner(s) signs a binder/contract of sale during the term of this employment agreement, the parties agree that the expiration date set forth below shall be extended
until the time that said contract of sale is fully performed or until such time as said contract fails to be performed either by its terms or because of the default of one of the
parties. Nothing herein contained is intended to reduce the term of this Agreement.
9. The Owner(s) agrees at all times to act in good faith to assist the BROKER in the performance of the BROKER'S obligations and to fully cooperate with the BROKER in the
BROKER'S efforts to find a buyer for the property and complete the transaction contemplated by this agreement..
RENTAL OF THE PROPERTY
10. Should the Owner(s) desire to rent the property or any portion thereof during the term of this agreement, the parties shall modify this agreement so as to specify the amount of
the rent desired by the Owner(s); the terms of the rental; the amount of commission to be paid to the BROKER.
11. In the event the tenant purchases the real property described in the PDS during the term of the tenancy or during the occupancy of the tenant where such occupancy exceeds
the original term, the Owner(s) agrees to pay the BROKER the total commission set forth in paragraph 6 hereof.
TERM OF AGREEMENT
12. This agreement shall commence on the date set forth below and shall terminate at midnight on ______________________________ .
MLS LI-C-CEA-ARB 12/08 ©Multiple Listing Service of Long Island Inc.
PAGE 3 OF 4
This contract is for use by Americas Real Estate Advisors. Use by any other party is illegal and voids the contract.
ML#___________________________
Property Address__________________________________________________________________________
List Price_______________________________________
LISTING AGREEMENT FOR REAL PROPERTY
EXCLUSIVE RIGHT TO SELL
Commission Rates for the Sale, Lease or Management of Property Shall be Negotiated between the BROKER1 and the Owner
MISCELLANEOUS PROVISIONS
13. Any notices required to be given under this agreement shall be in writing and may be given to the party by hand delivery of such notice, confirmed facsimile or by certified or
ordinary mail.
14. ALL ORAL OR PRIOR AGREEMENTS BETWEEN THE PARTIES ARE HEREBY MERGED INTO THIS AGREEMENT AND THE PARTIES AGREE THAT THEIR
RELATIONSHIP SHALL BE GOVERNED SOLELY BY THIS AGREEMENT AND NOT BY ANY OTHER PRIOR ORAL OR WRITTEN REPRESENTATIONS OR
AGREEMENTS. The parties agree that no change, amendment, modification or termination of this agreement shall be binding on any party unless the same shall be in writing
and signed by the parties hereto subsequent to the date of this agreement.
15. The Owner(s) understands and agrees that neither the Long Island Board of Realtors, Inc. nor the MLSLI are parties to this agreement and that the BROKER is not an agent
for either of said organizations and has no authority to make any representation, agreement or commitment with respect to either of said corporations other than those contained
in the printed portions hereof.
REAL PROPERTY LAW 294-b NOTICE
16. (a) Effective January 1, 2009, Broker Shall have the rights set forth in Real Property Law Section 294-b. Notice is hereby given to the seller that:
AT THE TIME OF CLOSING, YOU MAY BE REQUIRED TO DEPOSIT THE BROKER’S COMMISSION WITH THE COUNTY CLERK IN THE EVENT
THAT YOU DO NOT PAY THE BROKER HIS OR HER COMMISSION AS SET FORTH HEREIN. YOUR OBLIGATION TO DEPOSIT THE BROKER’S
COMMISSION WITH THE COUNTY CLERK MAY BE WAIVED BY THE BROKER.
(b) In the event the Broker waives his or her rights under Real Property Law Section 294-b for any reason (including, but not limited to, not filing or serving an Affidavit of
Entitlement specified in said Law), the parties agree that any dispute between the parties with respect to the commission earned by the Broker shall be resolved by arbitration
before National Arbitration and Mediation (NAM). The arbitration shall be governed by the rules of the National Arbitration and Mediation and judgment on the award rendered
by the arbitrator may be entered in any court having jurisdiction thereof.
(c) In any dispute submitted to arbitration pursuant to Section 16(b) above, the Owner shall establish an escrow account with a title insurance agent or company or with a party
mutually agreeable to Broker and Owner, and shall place into said escrow account an amount equal to the compensation set forth herein or the disputed amount, as the case
may be. The escrow monies shall be held in escrow until the parties rights to the escrow monies have been determined either (i) by the written agreement signed by both of
the parties, (ii) by an award of an arbitrator, (iii) by judgment or (iv) by some other process to which the parties agree in writing. In any action, proceeding, or arbitration to
enforce this Arbitration provision, the prevailing party shall be entitled to reasonable attorney’s fees, costs, and related expenses.
INDEMNITY
17. In the event any claim or action is commenced against the BROKER or a cooperating broker as a result of the BROKER or cooperating broker obeying the lawful instructions
of the Owner(s), then, and in such event, the Owner(s) hereby agrees to defend, indemnify and hold harmless the BROKER or cooperating broker in any such claim or action.
Owner shall have the right to select counsel in such event, subject to the approval of the BROKER and/or cooperating broker, which approval shall not be unreasonably
withheld.
18. With respect to the provisions of this agreement relating to compensation (Paragraph 6) and indemnity (Paragraph 17) cooperating brokers shall be third party beneficiaries of
this agreement.
PROPERTY CONDITION DISCLOSURE
19. The Seller is required by law to complete and sign a Property Condition Disclosure Statement and cause it, or a copy thereof, to be delivered to a buyer or buyer's agent prior
to the signing by the buyer of a binding contract of sale.
20. A copy of the Property Condition disclosure Statement containing the signatures of both the buyer and the seller must be attached to the real estate purchase contract.
21. If prior to closing or possession by the buyer the seller acquires knowledge which renders materially inaccurate a Property Condition Disclosure Statement previously provided,
the seller must deliver a revised Property Condition Disclosure Statement to the buyer as soon as practicable.
22. If the seller fails to so deliver a Property Condition Disclosure Statement, the buyer will be entitled to a credit in the amount of $500 against the purchase price of the property
upon the transfer of title.
EXPLANATIONS
23. An "EXCLUSIVE RIGHT TO SELL" listing means that if you, the Owner(s) of the property find a buyer for your house, or if another broker finds a buyer, you must pay the
agreed commission to the present broker.
24. An "EXCLUSIVE AGENCY" listing means that if you, the Owner(s) of the property find a buyer, you will not have to pay a commission to the broker. However, if another
broker finds a buyer, you will owe a commission to both the selling broker and your present broker.
EQUAL OPPORTUNITY IN HOUSING
25. The parties agree that the above listed property is to be marketed in compliance with all Federal, State, Municipal and Local Laws concerning discrimination in housing.
Wherever the word broker is capitalized (BROKER) in this agreement, it is intended to describe the real estate broker who is a party and signatory to this agreement and no other
broker.
Owner Signature
Owner Signature
1
Owner Resident Address
City/Town ________________________________ State
Home Phone
Other Phone
Date
Listing Agent
Email Address
MLS Office Name
Ruben Rodriguez
MLS LI-C-CEA-ARB 12/08 ©Multiple Listing Service of Long Island Inc.
Zip
Co-Listing Agent
PAGE 4 OF 4
This contract is for use by Americas Real Estate Advisors. Use by any other party is illegal and voids the contract.
New York State
DEPARTMENT OF STATE
Division of Licensing Services
P.O. Box 22001
Albany, NY 12201-2001
Customer Service: (518) 474-4429
www.dos.state.ny.us
New York State Disclosure Form for Buyer and Seller
THIS IS NOT A CONTRACT
New York State law requires real estate licensees who
are acting as agents of buyers or sellers of property to
advise the potential buyers or sellers with whom they
work of the nature of their agency relationship and the
rights and obligations it creates. This disclosure will help
you to make informed choices about your relationship
with the real estate broker and its sales agents.
Throughout the transaction you may receive more than
one disclosure form. The law may require each agent
assisting in the transaction to present you with this disclosure form. A real estate agent is a person qualified to
advise about real estate.
If you need legal, tax or other advice, consult with a
professional in that field.
Disclosure Regarding Real Estate
Agency Relationships
Seller’s Agent
A seller’s agent is an agent who is engaged by a seller to
represent the seller’s interests. The seller’s agent does this
by securing a buyer for the seller’s home at a price and on
terms acceptable to the seller. A seller’s agent has, without limitation, the following fiduciary duties to the seller:
reasonable care, undivided loyalty, confidentiality, full
disclosure, obedience and duty to account. A seller’s
agent does not represent the interests of the buyer. The
obligations of a seller’s agent are also subject to any specific provisions set forth in an agreement between the
agent and the seller. In dealings with the buyer, a seller’s
agent should (a) exercise reasonable skill and care in performance of the agent’s duties; (b) deal honestly, fairly
and in good faith; and (c) disclose all facts known to the
agent materially affecting the value or desirability of
property, except as otherwise provided by law.
Buyer’s Agent
A buyer’s agent is an agent who is engaged by a buyer to
represent the buyer’s interests. The buyer’s agent does
this by negotiating the purchase of a home at a price and
on terms acceptable to the buyer. A buyer’s agent has,
without limitation, the following fiduciary duties to the
buyer: reasonable care, undivided loyalty, confidentiality,
full disclosure, obedience and duty to account. A buyer’s
agent does not represent the interest of the seller. The obligations of a buyer’s agent are also subject to any specific provisions set forth in an agreement between the agent
and the buyer. In dealings with the seller, a buyer’s agent
should (a) exercise reasonable skill and care in performance of the agent’s duties; (b) deal honestly, fairly and
in good faith; and (c) disclose all facts known to the agent
materially affecting the buyer’s ability and/or willingness
to perform a contract to acquire seller’s property that are
not inconsistent with the agent’s fiduciary duties to the
buyer.
Broker’s Agents
A broker’s agent is an agent that cooperates or is engaged
by a listing agent or a buyer’s agent (but does not work
for the same firm as the listing agent or buyer’s agent) to
assist the listing agent or buyer’s agent in locating a
property to sell or buy, respectively, for the listing agent’s
seller or the buyer agent’s buyer. The broker’s agent does
not have a direct relationship with the buyer or seller and
the buyer or seller can not provide instructions or direction directly to the broker’s agent. The buyer and the seller therefore do not have vicarious liability for the acts of
the broker’s agent. The listing agent or buyer’s agent do
provide direction and instruction to the broker’s agent
and therefore the listing agent or buyer’s agent will have
liability for the acts of the broker’s agent.
Dual Agent
A real estate broker may represent both the buyer and seller if both the buyer and seller give their informed consent in writing. In such a dual agency situation, the agent
will not be able to provide the full range of fiduciary duties to the buyer and seller. The obligations of an agent
are also subject to any specific provisions set forth in an
agreement between the agent, and the buyer and seller.
An agent acting as a dual agent must explain carefully to
DOS-1736-a (Rev. 11/10)
contract.
both the buyer and seller that the agent is acting for the
other party as well. The agent should also explain the
possible effects of dual representation, including that by
consenting to the dual agency relationship the buyer and
seller are giving up their right to undivided loyalty. A
buyer or seller should carefully consider the possible consequences of a dual agency relationship before agreeing
to such representation. A seller or buyer may provide advance informed consent to dual agency by indicating the
same on this form.
Dual Agent with Designated Sales Agents
If the buyer and seller provide their informed consent in
writing, the principals and the real estate broker who
represents both parties as a dual agent may designate a
sales agent to represent the buyer and another sales agent
to represent the seller to negotiate the purchase and sale
of real estate. A sales agent works under the supervision
This form was provided to me by
of the real estate broker. With the informed consent of the
buyer and the seller in writing, the designated sales agent
for the buyer will function as the buyer’s agent representing the interests of and advocating on behalf of the buyer
and the designated sales agent for the seller will function
as the seller’s agent representing the interests of and advocating on behalf of the seller in the negotiations between the buyer and seller. A designated sales agent cannot provide the full range of fiduciary duties to the buyer
or seller. The designated sales agent must explain that
like the dual agent under whose supervision they function, they cannot provide undivided loyalty. A buyer or
seller should carefully consider the possible consequences of a dual agency relationship with designated
sales agents before agreeing to such representation. A seller or buyer may provide advance informed consent to
dual agency with designated sales agents by indicating
the same on this form.
Ruben Rodriguez
(print name of licensee) of
AREA
(print name of company, firm or brokerage), a licensed real estate broker acting in the interest of the:
(
✘ ) Seller as a (check relationship below)
(
) Buyer as a (check relationship below)
(
) Seller’s agent
(
) Buyer’s agent
(
) Broker’s agent
(
) Broker’s agent
(
✘ ) Dual agent
(
) Dual agent with designated sales agent
For advance informed consent to either dual agency or dual agency with designated sales agents complete section below:
(
✘ ) Advance informed consent dual agency
(
) Advance informed consent to dual agency with designated sales agents
is appointed to
If dual agent with designated sales agents is indicated above:
represent the buyer; and
is appointed to represent the seller in this transaction.
acknowledge receipt of a copy of this disclosure
(I) (We)
form: signature of {
Date:
} Buyer(s) and/or { ✘ } Seller(s):
Date:
DOS-1736-a (Rev. 11/10)
This contract is for use by Americas Real Estate Advisors. Use by any other party is illegal and voids
the contract.
SALES - DISCLOSURE FOR PRE-1978 HOUSING SALES
DISCLOSURE OF INFORMATION AND ACKNOWLEDGMENT
LEAD-BASED PAINT AND/OR LEAD-BASED PAINT HAZARDS
Seller’s Name:
EQUAL HOUSING
OPPORTUNITY
Property Address:
City/State/Zip/Phone:
Lead Warning Statement
Every purchaser of any interest in residential real property on which a residential dwelling was built prior to 1978 is
notified that such property may present exposure to lead from lead-based paint that may place young children at risk
of developing lead poisoning. Lead poisoning in young children may produce permanent neurological damage,
including learning disabilities, reduced intelligence quotient, behavorial problems, and impaired memory. Lead
poisoning also poses a particular risk to pregnant women. The seller of any interest in residential real property is
required to provide the buyer with any information on lead-based paint hazards from risk assessments or inspections
in the seller’s possession and notify the buyer of any known lead-based paint hazards. A risk assessment or
inspection for possible lead-based paint hazards is recommended prior to purchase.
Seller’s Disclosure (initial)
(a)
(b)
Presence of lead-based paint and/or lead-based paint hazards (check one below):
❐
Known lead-based paint and/or lead-based paint hazards are present in the housing (explain):
❐
Seller has no knowledge of lead-based paint and/or lead based paint hazards in the housing.
Records and Reports available to the seller (check one below):
❐
❐
Seller has provided the purchaser with all available records and reports pertaining to leadbased paint and/or lead-based paint hazards in the housing (list documents below):
Seller has no reports or records pertaining to lead-based paint and/or lead-based paint hazards
in the housing.
Purchaser’s Acknowledgement (initial)
(c)
Purchaser has received copies of all information listed above.
(d)
Purchaser has received the pamphlet Protect Your Family From Lead in Your Home.
(e)
Purchaser has (check one below):
❐
❐
Received a 10-day opportunity (or mutually agreed upon period) to conduct a risk assessment
or inspection for the presence of lead-based paint and/or lead-based paint hazards; or
Waived the opportunity to conduct a risk assessment or inspection for the presence of leadbased paint and/or lead-based paint hazards.
Agent’s Acknowledgement (initial)
(f)
Agent has informed the seller of the seller’s obligations under 42 U.S.C. 4852 d and is aware of
his/her responsibility to ensure compliance.
Certification of Accuracy
The following parties have reviewed the information above and certify, to the best of their knowledge, that the
information they have provided is true and accurate.
Seller:
Date:
Seller:
Date:
Purchaser:
Date:
Purchaser:
Date:
Agent:
Date:
Agent:
Date:
Form# 800S-8/96
contract.
Sellers Obligations Regarding
Property Condition Disclosure
As the seller of residential real property, you are required by law to
complete and sign a Property Condition Disclosure Statement as
prescribed by Real Property Law 462(12) and cause it, or a copy thereof, to
be delivered to a buyer or buyer's agent prior to the signing by the buyer
of a binding contract of safe. A copy of the Property Condition Disclosure
Statement containing the signatures of both the buyer and the seller must
be attached to the real estate purchase contract.
If you acquire knowledge which renders materially inaccurate a Property
Condition Disclosure Statement previously provided, you must deliver a
revised Properly Condition Disclosure Statement to the buyer as soon as
practicable. In no event, however, will you be required to provide a
revised Property Condition Disclosure Statement, after the transfer of title
from you to the buyer or after the buyer has commenced occupancy of
the property.
If you fail to deliver a Properly Condition Disclosure Statement to the buyer
prior to the buyer signing a binding contract of sale, the buyer will be
entitled to a credit in the amount of $500.00 against the purchase price of
the property upon the transfer of title.
I have received and read this disclosure notice.
Dated: _____________________ Seller: _____________________
Dated: _____________________ Seller: _____________________
Page 1
the contract.
OFFICE EXCLUSIVE
CERTIFICATION
Date:
TO
MULTIPLE LISTING SERVICE OF LONG ISLAND, INC.
300 SUNRISE HIGHWAY, WEST BABYLON, N.Y. 11704
I hereby certify that I have given
(Name of Realtor Office)
an exclusive listing on my property at
(Address of Property)
, a copy of which is attached hereto.
Said office has explained the advantages of The Multiple Listing Service, however,
for personal reasons I direct that this property not be published in The Multiple
Listing Service.
The exclusive listing runs from
(Expiration Date)
(Beginning Date)
.
to
(Owner)
Ruben Rodriguez
Salesperson Name (Print)
(Owner)
Firm Name
201 OldCountryRd Melville NY11747
Office Address
800.318.5110
Office Phone
MLS - LI - 2 (4/93)
the contract.
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 Making 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, of any one of the following: (A) felony
larceny, theft, fraud, or forgery, (B) money laundering or (C) tax evasion.
I/we certify under penalty of 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 the 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 date listed below or the date received by your
servicer.
______________________________________
Borrower Signature
____________________
Date
______________________________________
Co-Borrower Signature
____________________
Date
Short Sale Addendum to Exclusive Listing Agreement
This addendum is incorporated into the Exclusive Listing Agreement. ("Listing Agreement") between
___________________________________________("Seller") and Emerald City Realty (Broker) dated___________
regarding the property described as _____________________________________________("Premises") and is to
be considered part thereof. In the event this Addendum conflicts with the standard form section of the Listing
Agreement, then this Addendum shall control.
1. Acknowledgement of Short Sale: Seller acknowledges that based upon Information supplied to the Broker by the
Seller, the Broker has advised the Seller of the following: (1) That the current fair market value of the property may be
insufficient to discharge all debts and obligations secured by liens on the Premise as well as to pay brokers' fees,
transfer taxes and other costs of sale. (2) That sale of the Premises is likely to require approval by one or more
lienholders, and that a Lien holder is not obligated to approve the terms of the sale unless paid in full.
2. Broker Not Liable for Lender Decisions: Lienholders are not within the Broker's control. Broker shall not be liable
for any loss, damage or harm to the Seller resulting from; (a) Broker's communication with a lienholder, (b) a
lienholder's rejection of the short sale terms; (c) failure of a lienholder lo make a decision In a timely manner; or (d)
Imposition of terms or conditions by a lienholder.
3. Alternatives to Short Sale: Alternatives to a short sale may be available, Including, but not limited to the following;
(a) forbearance agreements or repayment plans with the Seller's lender(s) (b) loan modifications; (c).refinancing
programs, either with the Seller's lender(s) or with other lenders; (d) bankruptcy; (e) voluntary deed In lieu of
foreclosure.
4. Seller's Right to Consult with Others: Broker has further advised the Seller that the Seller Is free to consult an
attorney and/or tax advisor to discuss the possible credit and tax ramifications of a short sale and the alternatives to a
short sale. Seller is aware that Broker can neither provide tax advice nor legal advice.
5. Disclosure of Short Sale Status: Seller acknowledges that the Broker has advised that Seller that the Broker Is
obligated to disclose the status of any short sale. Seller hereby authorizes the Broker to identify the property as a
short sale in marketing and promotional materials and in the listing of the Premises. Broker is further authorized to
disclose to prospective buyers and their agents that the terms of the sale may be subject to third party approval and
that the transaction is likely to be a short sale. Broker shall have no liability for any loss, damage or harm to the Seller
from any such communication.
6. Authorization to Contact Third Party or Parties Regarding Short Sale: Seller hereby authorizes the Broker to
communicate with Sellers' lienholder(s) regarding the details of Seller's loan(s) and the possibility of that lienholder
accepting less than the total amount owed In exchange for a release of the lien.
7. Seller's Duties: Seller hereby agrees to cooperate with the Broker's efforts to negotiate a reduced payoff amount
by executing or providing any documentation required by the Seller's lienholders(s) In order to review or process the
short sale. Such documentation may include, but, Is not limited to the following; appraisal, copies of tax returns, W2
forms, 1099 forms, pay stubs, bank statements, statement of assets, medical statements, and documentation to
establish a hardship. Seller agrees to respond to Broker's requests promptly, accurately, and fully. Broker shall not be
responsible for an adverse decision (or the failure to make a decision in a timely manner) by a lienholder(s). Broker
shall not be responsible to verify any Information provided by Seller and Seller agrees to Indemnify, defend and hold
Broker harmless from all liability including attorney's fees and defense costs arising from Incorrect or untruthful
Information provided by Seller.
Date: ____ / ____ / ____
_______________________________
Seller
________________________________
Broker
_______________________________
Seller
Making Home Affordable Program
Request for Mortgage Assistance (RMA)
Request For Mortgage Assistance (RMA) page 1
COMPLETE ALL PAGES OF THIS FORM
Requesting mortgage assistance for mortgage loan number:
I/We want to:
Keep the property
Sell the property
The property is my/our:
Primary residence
Second home
Investment property
The property is:
Owner occupied
Renter occupied
Vacant
Borrower information
Borrower
Borrower’s name
Social Security number
Co-borrower
Co-borrower’s name
Date of birth
Social Security number
Date of birth
Home phone number
Home phone number
(
)
Cell phone number
(
)
Cell phone number
(
)
Work phone number
(
)
Work phone number
(
)
Email address
(
)
Email address
Mailing address
Mailing address (if different than borrower’s)
Have you contacted a credit-counseling agency for help?
Yes
No
If yes, complete counselor contact information below.
Counselor’s name: _____________________________
Counselor’s phone number: (
) _________________________
Counselor’s email: _____________________________
Is any borrower a service member?
Yes
No
If yes, have you recently been deployed away from your principal residence or recently received a permanent change of station order?
Yes
No
Have you filed for bankruptcy?
If yes:
Chapter 7
Chapter 11
Yes
No
Chapter 12
Chapter 13
Filing date: ___________________________________
Has your bankruptcy been discharged?
Request for Mortgage Assistance Form
Page 1 of 10
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No
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Bankruptcy case number: _________________________
Please note that if you have or will receive a discharge from a bankruptcy case, and the mortgage was not reaffirmed in the bankruptcy case, we
will only exercise our rights against the property and are not attempting any act to collect the discharged debt from you personally. Additionally,
your decision to discuss workout options with us is strictly voluntary. You are not obligated to pursue any workout options discussed with us. At
your request, we will immediately terminate any such discussions should you no longer wish to pursue these options.
How many single family properties other than your principal residence do you and/or any co-borrower(s) own individually,
jointly, or with others?
_____________
Has the mortgage on your principal residence ever had a Home Affordable Modification Program (HAMP) trial period plan
or permanent modification?
Yes
No
Has the mortgage on any other property that you or any co-borrower own had a permanent HAMP modification?
Yes
No
If yes, how many? _____________
Are you or any co-borrower currently in or being considered for a HAMP trial period plan on a property other than your
principal residence?
Yes
No
Principal residence information
Note: If you are requesting mortgage assistance, you must complete this section even if you are not seeking mortgage
assistance on your principal residence.
Principal residence loan number
Principal residence servicer name
Property address (if same as mailing address, write “same”)
Number of people who live in the home
Is this property listed for sale?
Yes
No
If yes, what was property listing date? _______________________
Have you received an offer on the property?
Date of offer: ___________________
Yes
No
Amount of offer: $______________________
Agent/Agency name: _________________________________
For sale by owner?
Yes
Who pays the real estate tax bill on your property?
Closing date: _____________________
Agent/Agency phone number (
)______________________
No
I do
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Are the taxes current?
Yes
Monthly condominium or homeowners association fee?
Yes
Are fees paid current?
Yes
No
$ __________________________
No
Paid to (Name and Address) ______________________________
Who pays the homeowners insurance policy for your property? I do
Servicer does
Is the policy current?
Yes
Paid by condominium or homeowners association (HOA) No If paid by you or your condominium or HOA , name of insurance company:__________________________
Insurance company phone number: (
)____________
Annual homeowners insurance: $___________________________
If there are additional liens/mortgages or judgments on this property, name the person(s), company or firm and phone
number(s).
Lien holder's name/Servicer:_____________________________
Phone number: (
) ___________________________
Loan number: _______________________________________
Balance: $_____________________________________
Lien holder's name/Servicer:_____________________________
Phone number: (
Loan number: _______________________________________
Balance: $_____________________________________
) ___________________________
Complete this section ONLY if you are requesting mortgage assistance with a property that is not your principal residence.
Principal residence servicer name: __________________________________
Principal residence phone number: (
) ___________________________
Is the mortgage on your principal residence paid?
Yes
No
If no, number of months your payment is past due (if known):______________
Hardship Affidavit
I am requesting review under the Making Home Affordable Program. I am having difficulty making my monthly payment because of financial
difficulties created by (check all that apply):
My household income has been reduced. For example: reduced pay or hours, decline in business earnings, death, disability or divorce of a
borrower or co-borrower.
My monthly debt payments are excessive and I am overextended with my creditors. Debt includes credit cards, home equity or other debt.
My expenses have increased. For example: monthly mortgage payment reset, high medical or health care costs, uninsured losses, increased
utilities or property taxes.
My cash reserves, including all liquid assets, are insufficient to maintain my current mortgage payment and cover basic living expenses at the
same time.
I am unemployed and (a) I am receiving/will receive unemployment benefits or (b) my unemployment benefits ended less than 6 months ago.
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Other
Explanation (continue on back of page 3 if necessary):
_________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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Income/expenses for household
Important note: All income must be documented.
Combined income and expense of borrower and co-borrower
You are not required to disclose child support, alimony or separation maintenance income unless you choose to have it considered by your
servicer.
1
2
3
Monthly household income
Monthly household expenses/debt
Household assets
Monthly gross wages
Overtime
$
First mortgage payment
$
$
Second mortgage payment/
other liens
$
Homeowners insurance1
$
Property taxes2
$
Borrower start date of
employment (MMDDYYYY)
Co-borrower start date of
employment (MMDDYYYY)
Borrower other employment
start date (MMDDYYYY) (If
borrower has a second job)
Co-borrower other employment
start date (MMDDYYYY)
Child
support/alimony/separation
maintenance
Non-taxable Social
Security/Social Security
Disability Insurance
$
$
Taxable Social Security benefits $
Other monthly income from
pensions, annuities or
retirement plans
Tips, commissions and bonus
income
$
$
Self-employment income
$
Unemployment income
$
Start date of unemployment
(MMDDYYYY)
Credit cards/installment
loan(s) (total minimum
payment per month)
Alimony/separation
maintenance/child support
payments
Net rental expenses/
property maintenance
expenses
$
$
$
Savings/money market
account(s)
$
$
Certificate(s) of deposit
(CDs)
$
$
$
$
$
Homeowners association/
condominium fees
$
Child care expenses
$
Car payments, including car
$
lease payments
Car insurance/gas/
maintenance
Health insurance/medical
expenses
Life insurance premiums
(not withheld from pay)
Checking account(s)
Stocks/bond(s)
$
$
Other cash on hand
$
$
Other real estate (estimated
value)
$
$
Other
$
$
$
Groceries
$
$
$
Gross rent received 3
$
Water/sewer/utilities
$
Boarder income
$
Internet/cable/satellite/cell
phone/home phone
$
Food stamps/Welfare
$
Personal loans/tuition
$
Other (investment income,
royalties, interest, dividends,
etc.)
$
Charitable contributions
$
Do not include retirement plans when
calculating assets (401(k), pension funds,
annuities, IRAs, Keogh plans, etc.)
Mortgage payments for other
properties 4
Total (gross income)
$
Other
$
Total debts/expenses
$
Total assets
$
1. Only include your homeowners insurance payment if you pay this amount yourself.
2. Only include your property tax payments if you pay them yourself.
3. Include rental income received from all properties you own EXCEPT a property for which you are seeking mortgage assistance in the following
section.
4. Include mortgage payments on all properties you own EXCEPT your principal residence and the property for which you are seeking mortgage
assistance in the following section.
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Information about your other properties
Other properties owned
You must provide information about all properties that you or the co-borrower own, other than your principal residence and the property that
you are requesting assistance for. (See below.) Use additional sheets if necessary.
Other Property #1
Property address:_____________________________________________________________________________________
Loan number:______________________________________
Servicer name: ____________________________________
Mortgage balance: $__________________________________
Current value: $___________________________________
Property is:
Vacant
Second or seasonal home
Rented
Gross monthly rent: $_________________________________
Monthly mortgage payment*: $_________________________
Other Property #2
Loan number:______________________________________
Servicer name: ____________________________________
Current value: $___________________________________
Property is:
Vacant
Rented
Other Property #3
Loan number:______________________________________
Servicer name: ____________________________________
Current value: $___________________________________
Property is:
Vacant
Rented
* The amount of the monthly payment made to your Servicer – including, if applicable, monthly principal, interest, real property taxes and
insurance premiums.
Other property for which assistance is requested
Complete this section ONLY if you are requesting mortgage assistance with a property that is not your principal residence.
I am requesting mortgage assistance with a rental property.
Yes
No
I am requesting mortgage assistance with a second or seasonal home.
Yes
If yes to either, I want to:
Keep the property
No
Sell the property
Loan number:_______________________________________
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Do you have a second mortgage on the property?
Yes
No
If yes, Servicer name:________________________________
Loan number:_____________________________________
Do you have condominium or homeowner association (HOA) fees?
Yes
No
If yes, monthly fee: $________________________________
Are HOA fees paid current?
Yes
No
Name and address that fees are paid to:______________________________________________________________________
Does your mortgage payment include taxes and insurance?
If no, are the taxes and insurance paid current?
Yes
Yes
No
No
If insurance is paid by you or HOA, name of insurance company:__________________________ Insurance company phone number:
(
)____________
Annual homeowners insurance: $________________________ Annual property taxes: $_____________________________
If requesting assistance with a rental property, property is currently:
Vacant and available for rent
Occupied without rent by your legal dependent, parent or grandparent as their principal residence
Occupied by a tenant as their principal residence
Other __________________________________________________
If rental property is occupied by a tenant:
Term of lease /occupancy:
____ / ____/________ – ____ / ____/________
MM / DD / YYYY
MM / DD / YYYY
Gross monthly rent: $________________________________
If rental property is vacant, describe efforts to rent property: _____________________________________________________
________________________________________________________________________________________________
If applicable, describe relationship of and duration of non-rent paying occupant of rental property:____________________________
________________________________________________________________________________________________
Is the property for sale?
Yes
No
If yes, listing agent's name: ______________________________
Phone number: (_____)___________________________
List date: ___________________________________________
Have you received a purchase offer?
Yes
No
Amount of offer: $____________________________________
Closing date:___________________________________
Rental Property Certification
You must complete this certification if you are requesting a mortgage modification with respect to a rental property.
By checking this box and initialing below, I am requesting a mortgage modification under MHA with respect to the rental property as
previously described and I hereby certify under penalty of perjury that each of the following statements is true and correct with respect to
that property:
1. I intend to rent the property to a tenant or tenants for at least five years following the effective date of my mortgage modification. I
understand that the servicer, the U.S. Department of the Treasury, or their respective agents may ask me to provide evidence of my intention
to rent the property during such time. I further understand that such evidence must show that I used reasonable efforts to rent the property
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to a tenant or tenants on a year-round basis, if the property is or becomes vacant during such five-year period. Note: The term “reasonable
efforts” includes, without limitation, advertising the property for rent in local newspapers, websites or other commonly used forms of
written or electronic media, and/or engaging a real estate or other professional to assist in renting the property, in either case, at or below
market rent.
2. The property is not my secondary residence and I do not intend to use the property as a secondary residence for at least five years
following the effective date of my mortgage modification. I understand that if I do use the property as a secondary residence during such
five-year period, my use of the property may be considered to be inconsistent with the certifications I have made herein. Note: The term
“secondary residence” includes, without limitation, a second home, vacation home or other type of residence that I personally use or occupy
on a part-time, seasonal or other basis.
3. I do not own more than five (5) single-family homes (i.e., one-to-four unit properties) (exclusive of my principal residence).
Notwithstanding the foregoing certifications, I may at any time sell the property, occupy it as my principal residence, or
permit my legal dependent, parent or grandparent to occupy it as their principal residence with no rent charged or collected,
none of which will be considered to be inconsistent with the certifications made herein.
This certification is effective on the date I signed this form or the date the RMA is received by your Servicer.
Initials: Borrower: ________ Co-borrower: _______
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 Making 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, of any one of the following: (A) felony larceny, theft, fraud, or forgery, (B) money
laundering or (C) tax evasion.
I certify under penalty of perjury that I 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 understand that the servicer, the U.S. Department of the Treasury, or their respective 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 have not been
convicted of such crimes. I also understand that knowingly submitting false information may violate Federal law. This certification is effective on
the date I signed this form or the date this RMA is received by your servicer.
Borrower and Co- Borrower Acknowledgment and Agreement
1. I certify that all of the information in this RMA is truthful and the hardship(s) identified above has contributed to submission of this request
for mortgage relief.
2. I understand and acknowledge that the Servicer, the U.S. Department of the Treasury, the owner or guarantor of my mortgage loan, or their
respective agents may investigate the accuracy of my statements, may require me to provide additional supporting documentation and that
knowingly submitting false information may violate Federal and other applicable law.
3. I authorize and give permission to the Servicer, the U.S. Department of Treasury, and their respective agents, to assemble and use a current
consumer report on all borrowers obligated on the loan to investigate each borrower’s eligibility for MHA and the accuracy of my statements and
any documentation that I provide in connection with my request for assistance. I understand that these consumer reports may include, without
limitation, a credit report, and be assembled and used at any point during the application process to assess each borrower’s eligibility thereafter.
4. I understand that if I have intentionally defaulted on my existing mortgage, engaged in fraud or if it is determined that any of my statements or
any information contained in the documentation that I provide are materially false and that I was ineligible for assistance under MHA, the
Servicer, the U.S. Department of the Treasury, or their respective agents may terminate my participation in MHA, including any right to future
benefits and incentives that otherwise would have been available under the program, and also may seek other remedies available at law and in
equity, such as recouping any benefits or incentives previously received.
5. I certify that any property for which I am requesting assistance is a habitable residential property that is not subject to a condemnation notice.
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6. I certify that I am willing to provide all requested documents and to respond to all Servicer communications in a timely manner. I understand
that time is of the essence.
7. I understand that the Servicer will use the information I provide to evaluate my eligibility for available relief options and foreclosure
alternatives, but the Servicer is not obligated to offer me assistance based solely on the representations in this document or other documentation
submitted in connection with my request.
8. I am willing to commit to credit counseling if it is determined that my financial hardship is related to excessive debt.
9. If I am eligible for assistance under MHA, and I accept and agree to all terms of an MHA notice, plan or agreement, I also agree that the terms
of this Acknowledgment and Agreement are incorporated into such notice, plan or agreement by references as if set forth therein full. My first
timely payment, if required, following my Servicer’s determination and notification of my eligibility or prequalification for MHA assistance will
serve as my acceptance of the terms set forth in the notice, plan, or agreement sent to me.
10. I understand that the Servicer will collect and record personal information, including, but not limited to, my name, address, telephone
number, Social Security number, credit score, income, payment history, government monitoring information, and information about account
balances and activity. I understand and consent to the disclosure of my personal information and the terms of any Making Home Affordable
Agreement by Servicer to (a) the U.S. Department of the Treasury or its agents, (b) Fannie Mae and Freddie Mac in connection with their
responsibilities under the Homeowner Affordability and Stability Plan; (c) any investor, insurer, guarantor or Servicer that owns, insures,
guarantees or services my first lien or subordinate lien (if applicable) mortgage loan(s); (d) companies and or individuals that perform support
services in conjunction with home preservation mortgage assistance efforts; (e) auditors, including but not limited to independent auditors,
regulators and agencies and (f) any HUD-certified housing counselor.
11. I consent to being contacted concerning this request for mortgage assistance at any email address or cellular or mobile telephone number I
have provided to the Servicer. This includes text messages and telephone calls to my cellular or mobile telephone.
Borrower signature(s):
The undersigned certifies under penalty of perjury that all statements in this document are true and correct.
_____________________________________________
Borrower signature
_______________________________________________
Co-borrower signature
_____________________________________________
Borrower Social Security number
_______________________________________________
Co-borrower Social Security number
_____________________________________________
Borrower date of birth
_______________________________________________
Co-borrower date of birth
_____________________________________________
Date
_______________________________________________
Date
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Contacts — if you have questions
If you have questions about this document or your available options, please contact your home preservation specialist.
If you have questions about your options that your Servicer cannot answer or if you need further counseling, call the Homeowner’s HOPE™
Hotline at 1-888-995-HOPE (4673). A Hotline counselor will help you by answering questions about your available options and providing you
with free HUD-certified counseling services in English and Spanish.
Information for government monitoring purposes
The following information is requested by the federal government in order to monitor compliance with federal statutes that prohibit
discrimination in housing. You are not required to furnish this information, but are encouraged to do so. The law provides that a
lender or Servicer may not discriminate either on the basis of this information, or on whether you choose to furnish it. If you
furnish the information, please provide both ethnicity and race. For race, you may check more than one designation. If you do not furnish
ethnicity, race, or sex, the lender or Servicer is required to note the information on the basis of visual observation and surname if you have made
this request for assistance in person. If you do not wish to furnish the information, please check the box below.
Borrower
Ethnicity:
Race:
Sex:
I do not wish to furnish this information.
Hispanic or Latino
Not Hispanic or Latino
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Female
Male
Co-borrower
Ethnicity:
Race:
Sex:
I do not wish to furnish this information.
Hispanic or Latino
Not Hispanic or Latino
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Female
Male
To be completed by interviewer
This application was taken by:
Face-to-face interview
Mail
Telephone
Internet
Interviewer’s name (print or type)
Interviewer’s ID number
Interviewer’s signature
Date
Interviewer’s phone number (include area code)
Name /Address of interviewer’s employer
Notice to Borrower
Be advised that you are signing this document under penalty of perjury. Any misstatement of material fact made in the completion of these
documents including but not limited to misstatement regarding your occupancy in your home, hardship circumstances, and/or income will
subject you to potential criminal investigation and prosecution for the following crimes: perjury, false statements, mail fraud, and wire fraud.
The information contained in these documents is subject to examination and verification. Any potential misrepresentation will be referred to
the appropriate law enforcement authority for investigation and prosecution.
If you are aware of fraud, waste, abuse, mismanagement or misrepresentations affiliated with the Troubled Asset Relief
Program, please contact the SIGTARP Hotline by calling 1-877-SIG-2009 (toll-free), 202-622-4559 (fax), or
www.sigtarp.gov. Mail can be sent to Hotline Office of the Special Inspector General for Troubled Asset Relief
Program, 1801 L St. NW, Washington, DC 20220.
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4506-T
Form
(Rev. January 2012)
Department of the Treasury
Internal Revenue Service
Request for Transcript of Tax Return
▶
Request may be rejected if the form is incomplete or illegible.
OMB No. 1545-1872
Tip. Use Form 4506-T to order a transcript or other return information free of charge. See the product list below. You can quickly request transcripts by using
our automated self-help service tools. Please visit us at IRS.gov and click on "Order a Transcript" or call 1-800-908-9946. If you need a copy of your return, use
Form 4506, Request for Copy of Tax Return. There is a fee to get a copy of your return.
1a Name shown on tax return. If a joint return, enter the name
shown first.
1b First social security number on tax return, individual taxpayer identification
number, or employer identification number (see instructions)
2a If a joint return, enter spouse’s name shown on tax return.
2b Second social security number or individual taxpayer
identification number if joint tax return
3 Current name, address (including apt., room, or suite no.), city, state, and ZIP code (see instructions)
4 Previous address shown on the last return filed if different from line 3 (see instructions)
5 If the transcript or tax information is to be mailed to a third party (such as a mortgage company), enter the third party’s name, address,
and telephone number.
Caution. If the tax transcript is being mailed to a third party, ensure that you have filled in lines 6 through 9 before signing. Sign and date the form once
you have filled in these lines. Completing these steps helps to protect your privacy. Once the IRS discloses your IRS transcript to the third party listed
on line 5, the IRS has no control over what the third party does with the information. If you would like to limit the third party's authority to disclose your
transcript information, you can specify this limitation in your written agreement with the third party.
Transcript requested. Enter the tax form number here (1040, 1065, 1120, etc.) and check the appropriate box below. Enter only one tax form
number per request. ▶
6
a
Return Transcript, which includes most of the line items of a tax return as filed with the IRS. A tax return transcript does not reflect
changes made to the account after the return is processed. Transcripts are only available for the following returns: Form 1040 series,
Form 1065, Form 1120, Form 1120A, Form 1120H, Form 1120L, and Form 1120S. Return transcripts are available for the current year
and returns processed during the prior 3 processing years. Most requests will be processed within 10 business days . . . . . .
b
Account Transcript, which contains information on the financial status of the account, such as payments made on the account, penalty
assessments, and adjustments made by you or the IRS after the return was filed. Return information is limited to items such as tax liability
and estimated tax payments. Account transcripts are available for most returns. Most requests will be processed within 30 calendar days
.
c
Record of Account, which provides the most detailed information as it is a combination of the Return Transcript and the Account
Transcript. Available for current year and 3 prior tax years. Most requests will be processed within 30 calendar days . . . . . . .
7
8
Verification of Nonfiling, which is proof from the IRS that you did not file a return for the year. Current year requests are only available
after June 15th. There are no availability restrictions on prior year requests. Most requests will be processed within 10 business days . .
Form W-2, Form 1099 series, Form 1098 series, or Form 5498 series transcript. The IRS can provide a transcript that includes data from
these information returns. State or local information is not included with the Form W-2 information. The IRS may be able to provide this
transcript information for up to 10 years. Information for the current year is generally not available until the year after it is filed with the IRS.
For example, W-2 information for 2010, filed in 2011, will not be available from the IRS until 2012. If you need W-2 information for retirement
purposes, you should contact the Social Security Administration at 1-800-772-1213. Most requests will be processed within 45 days . . .
Caution. If you need a copy of Form W-2 or Form 1099, you should first contact the payer. To get a copy of the Form W-2 or Form 1099 filed
with your return, you must use Form 4506 and request a copy of your return, which includes all attachments.
9
Year or period requested. Enter the ending date of the year or period, using the mm/dd/yyyy format. If you are requesting more than four
years or periods, you must attach another Form 4506-T. For requests relating to quarterly tax returns, such as Form 941, you must enter
each quarter or tax period separately.
Check this box if you have notified the IRS or the IRS has notified you that one of the years for which you are requesting a transcript
involved identity theft on your federal tax return . . . . . . . . . . . . . . . . . . . . . . . . . . .
Caution. Do not sign this form unless all applicable lines have been completed.
Signature of taxpayer(s). I declare that I am either the taxpayer whose name is shown on line 1a or 2a, or a person authorized to obtain the tax
information requested. If the request applies to a joint return, either husband or wife must sign. If signed by a corporate officer, partner, guardian, tax
matters partner, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify that I have the authority to execute Form 4506-T on
behalf of the taxpayer. Note. For transcripts being sent to a third party, this form must be received within 120 days of the signature date.
Phone number of taxpayer on line
1a or 2a
▲ ▲ ▲
Sign
Here
Signature (see instructions)
Date
Title (if line 1a above is a corporation, partnership, estate, or trust)
Spouse’s signature
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
Date
Cat. No. 37667N
Form 4506-T (Rev. 1-2012)
Form 4506-T (Rev. 1-2012)
Page
Section references are to the Internal Revenue
Code unless otherwise noted.
What's New
The IRS has created a page on IRS.gov for
information about Form 4506-T at
www.irs.gov/form4506. Information about any
recent developments affecting Form 4506-T
(such as legislation enacted after we released it)
will be posted on that page.
General Instructions
CAUTION. Do not sign this form unless all
applicable lines have been completed.
Purpose of form. Use Form 4506-T to request
tax return information. You can also designate
(on line 5) a third party to receive the information.
Taxpayers using a tax year beginning in one
calendar year and ending in the following year
(fiscal tax year) must file Form 4506-T to request
a return transcript.
Note. If you are unsure of which type of transcript
you need, request the Record of Account, as it
provides the most detailed information.
Tip. Use Form 4506, Request for Copy of
Tax Return, to request copies of tax returns.
Where to file. Mail or fax Form 4506-T to
the address below for the state you lived in,
or the state your business was in, when that
return was filed. There are two address charts:
one for individual transcripts (Form 1040 series
and Form W-2) and one for all other transcripts.
If you are requesting more than one transcript
or other product and the chart below shows two
different addresses, send your request to the
address based on the address of your most
recent return.
Automated transcript request. You can quickly
request transcripts by using our automated
self-help service tools. Please visit us at IRS.gov
and click on “Order a Transcript” or call
1-800-908-9946.
Chart for individual transcripts
(Form 1040 series and Form W-2
and Form 1099)
If you filed an
individual return
and lived in:
Mail or fax to the
“Internal Revenue
Service” at:
Alabama, Kentucky,
Louisiana, Mississippi,
Tennessee, Texas, a
foreign country, American
Samoa, Puerto Rico,
Guam, the
Commonwealth of the
Northern Mariana Islands,
the U.S. Virgin Islands, or
A.P.O. or F.P.O. address
RAIVS Team
Stop 6716 AUSC
Austin, TX 73301
Alaska, Arizona, Arkansas,
California, Colorado,
Hawaii, Idaho, Illinois,
Indiana, Iowa, Kansas,
Michigan, Minnesota,
Montana, Nebraska,
Nevada, New Mexico,
North Dakota, Oklahoma,
Oregon, South Dakota,
Utah, Washington,
Wisconsin, Wyoming
RAIVS Team
Stop 37106
Fresno, CA 93888
Connecticut, Delaware,
District of Columbia,
Florida, Georgia, Maine,
Maryland, Massachusetts,
Missouri, New Hampshire,
New Jersey, New York,
North Carolina, Ohio,
Pennsylvania, Rhode
Island, South Carolina,
Vermont, Virginia, West
Virginia
RAIVS Team
Stop 6705 P-6
Kansas City, MO 64999
512-460-2272
559-456-5876
816-292-6102
Chart for all other transcripts
If you lived in
or your business
was in:
Alabama, Alaska,
Arizona, Arkansas,
California, Colorado,
Florida, Hawaii, Idaho,
Iowa, Kansas,
Louisiana, Minnesota,
Mississippi,
Missouri, Montana,
Nebraska, Nevada,
New Mexico,
North Dakota,
Oklahoma, Oregon,
South Dakota, Texas,
Utah, Washington,
Wyoming, a foreign
country, or A.P.O. or
F.P.O. address
Connecticut,
Delaware, District of
Columbia, Georgia,
Illinois, Indiana,
Kentucky, Maine,
Maryland,
Massachusetts,
Michigan, New
Hampshire, New
Jersey, New York,
North Carolina,
Ohio, Pennsylvania,
Rhode Island, South
Carolina, Tennessee,
Vermont, Virginia,
West Virginia,
Wisconsin
Mail or fax to the
“Internal Revenue
Service” at:
RAIVS Team
P.O. Box 9941
Mail Stop 6734
Ogden, UT 84409
801-620-6922
RAIVS Team
P.O. Box 145500
Stop 2800 F
Cincinnati, OH 45250
859-669-3592
Line 1b. Enter your employer identification
number (EIN) if your request relates to a
business return. Otherwise, enter the first
social security number (SSN) or your individual
taxpayer identification number (ITIN) shown on
the return. For example, if you are requesting
Form 1040 that includes Schedule C (Form
1040), enter your SSN.
Line 3. Enter your current address. If you use a
P. O. box, include it on this line.
Line 4. Enter the address shown on the last
return filed if different from the address entered
on line 3.
Note. If the address on lines 3 and 4 are different
and you have not changed your address with the
IRS, file Form 8822, Change of Address.
Line 6. Enter only one tax form number per
request.
Signature and date. Form 4506-T must be
signed and dated by the taxpayer listed on line
1a or 2a. If you completed line 5 requesting the
information be sent to a third party, the IRS must
receive Form 4506-T within 120 days of the date
signed by the taxpayer or it will be rejected.
Ensure that all applicable lines are completed
before signing.
2
Individuals. Transcripts of jointly filed tax
returns may be furnished to either spouse. Only
one signature is required. Sign Form 4506-T
exactly as your name appeared on the original
return. If you changed your name, also sign your
current name.
Corporations. Generally, Form 4506-T can be
signed by: (1) an officer having legal authority to
bind the corporation, (2) any person designated
by the board of directors or other governing
body, or (3) any officer or employee on written
request by any principal officer and attested to
by the secretary or other officer.
Partnerships. Generally, Form 4506-T can be
signed by any person who was a member of the
partnership during any part of the tax period
requested on line 9.
All others. See section 6103(e) if the taxpayer
has died, is insolvent, is a dissolved corporation,
or if a trustee, guardian, executor, receiver, or
administrator is acting for the taxpayer.
Documentation. For entities other than
individuals, you must attach the authorization
document. For example, this could be the letter
from the principal officer authorizing an
employee of the corporation or the letters
testamentary authorizing an individual to act for
an estate.
Privacy Act and Paperwork Reduction Act
Notice. We ask for the information on this form
to establish your right to gain access to the
requested tax information under the Internal
Revenue Code. We need this information to
properly identify the tax information and respond
to your request. You are not required to request
any transcript; if you do request a transcript,
sections 6103 and 6109 and their regulations
require you to provide this information, including
your SSN or EIN. If you do not provide this
information, we may not be able to process your
request. Providing false or fraudulent information
may subject you to penalties.
Routine uses of this information include giving
it to the Department of Justice for civil and
criminal litigation, and cities, states, the District
of Columbia, and U.S. commonwealths and
possessions for use in administering their tax
laws. We may also disclose this information to
other countries under a tax treaty, to federal and
state agencies to enforce federal nontax criminal
laws, or to federal law enforcement and
intelligence agencies to combat terrorism.
You are not required to provide the
information requested on a form that is subject
to the Paperwork Reduction Act unless the form
displays a valid OMB control number. Books or
records relating to a form or its instructions must
be retained as long as their contents may
become material in the administration of any
Internal Revenue law. Generally, tax returns and
return information are confidential, as required by
section 6103.
The time needed to complete and file Form
4506-T will vary depending on individual
circumstances. The estimated average time is:
Learning about the law or the form, 10 min.;
Preparing the form, 12 min.; and Copying,
assembling, and sending the form to the IRS,
20 min.
If you have comments concerning the
accuracy of these time estimates or suggestions
for making Form 4506-T simpler, we would be
happy to hear from you. You can write to:
Internal Revenue Service
Tax Products Coordinating Committee
SE:W:CAR:MP:T:M:S
1111 Constitution Ave. NW, IR-6526
Washington, DC 20224
Do not send the form to this address. Instead,
see Where to file on this page.
UNIFORM BORROWER ASSISTANCE FORM
If you are experiencing a temporary or long-term hardship and need help, you must complete and submit this form along with
other required documentation to be considered for available solutions. On this page, you must disclose information about (1)
you and your intentions to either keep or transition out of your home; (2) the property’s status; (3) real estate taxes; (4)
homeowner’s insurance premiums; (5) bankruptcy; (6) your credit counseling agency, and (7) other liens, if any, on your
property.
On Page 2, you must disclose information about all of your income, expenses and assets. Page 2 also lists the required income
documentation that you must submit in support of your request for assistance. Then on Page 3, you must complete the
Hardship Affidavit in which you disclose the nature of your hardship. The Hardship Affidavit informs you of the required
documentation that you must submit in support of your hardship claim.
NOTICE: In addition, when you sign and date this form, you will make important certifications, representations and
agreements, including certifying that all of the information in this Borrower Assistance Form is accurate and truthful
and any identified hardship has contributed to your submission of this request for mortgage relief.
REMINDER: The Borrower Response Package you need to return consists of: (1) this completed, signed and dated Borrower
Assistance Form; (2) completed and signed IRS Form 4506T-EZ; (3) required income documentation, and (4) required hardship
documentation.
Loan I.D. Number
(usually found on your monthly mortgage statement)
I want to:
Keep the Property
Sell the Property
The property is currently:
My Primary Residence
A Second Home
An Investment Property
The property is currently:
Owner Occupied
Renter occupied
Vacant
BORROWER
CO-BORROWER
BORROWER’S NAME
SOCIAL SECURITY NUMBER
CO-BORROWER’S NAME
DATE OF BIRTH
SOCIAL SECURITY NUMBER
HOME PHONE NUMBER WITH AREA CODE
HOME PHONE NUMBER WITH AREA CODE
CELL OR WORK NUMBER WITH AREA CODE
CELL OR WORK NUMBER WITH AREA CODE
DATE OF BIRTH
MAILING ADDRESS
PROPERTY ADDRESS (IF SAME AS MAILING ADDRESS, JUST WRITE SAME)
EMAIL ADDRESS
Is the property listed for sale?
Yes
No
If yes, what was the listing date?
If property has been listed for sale, have you received an offer on the
property?
Yes
No
Date of offer:
Amount of Offer: $
Agent’s Name:
Agent’s Phone Number:
For Sale by Owner?
Yes
No
Do you have condominium or homeowner association (HOA) fees?
Total monthly amount: $
Name and address that fees are paid to:
Have you filed for bankruptcy?
If yes:
Has your bankruptcy been discharged?
Fannie Mae/Freddie Mac Form 710
Yes
Chapter 7
Yes
No
Chapter 13
No
Have you contacted a credit-counseling agency for help?
Yes
If yes, please complete the counselor contact information below:
Counselor’s Name:
Agency’s Name:
Counselor’s Phone Number:
Counselor’s Email Address:
Yes
No
Filing Date:
Bankruptcy case number:
Page 1 of 4
06/11
No
Monthly Household Income
Monthly Household
Expenses/Debt
Household Assets (associated with
the property and/or borrower(s)
Monthly Gross wages
$
First Mortgage Payment
$
Checking Account(s)
$
Overtime
$
Second Mortgage Payment
$
Checking Account(s)
$
Child Support / Alimony*
$
Homeowner’s Insurance
$
Savings / Money Market
$
Non-taxable social
$
Property Taxes
$
CDs
$
$
Credit Cards / Installment
$
Stocks / Bonds
$
$
Other Cash on Hand
$
$
Other Real Estate
$
security/SSDI
Taxable SS benefits or other
monthly income from
Loan(s) (total minimum
annuities or retirement plans
payment per month)
Tips, commissions, bonus and
$
self-employed income
Rents Received
Alimony, child support
payments
$
Car Lease Payments
(estimated value)
Unemployment Income
$
HOA/Condo Fees/Property
$
Maintenance
Food Stamps/Welfare
$
Other
$
_____________________
Mortgage Payments on
$
$
$
$
other properties
Other
$
_____________________
Other
_____________________
Total (Gross income)
$
Total Debt/Expenses
$
Total Assets
$
*Notice: Alimony, child support, or separate maintenance income need not be revealed if you do not choose to have it considered for repaying this loan.
Lien Holder’s Name
Balance / Interest Rate
Loan Number
Required Income Documentation
Do you earn a wage?
For each borrower who is a salaried employee or
hourly wage earner, include the most recent pay
stub that reflects at least 30 days of year-to-date
earnings for each borrower.
Are you self-employed?
For each borrower who receives self-employed income, include a complete, signed
individual federal income tax return and, as applicable, the business tax return; AND either
the most recent signed and dated quarterly or year-to-date profit/loss statement that
reflects activity for the most recent three months; OR copies of bank statements for the
business account for the last two months evidencing continuation of business activity.
Do you have any additional sources of income? Provide for each borrower as applicable:
“Other Earned Income” such as bonuses, commissions, housing allowance, tips, or overtime:
 Reliable third-party documentation describing the amount and nature of the income (e.g., employment contract or printouts documenting
tip income).
Social Security, disability or death benefits, pension, public assistance, or adoption assistance:
 Documentation showing the amount and frequency of the benefits, such as letters, exhibits, disability policy or benefits statement from the
provider, and
 Documentation showing the receipt of payment, such as copies of the two most recent bank statements showing deposit amounts.
Rental income:
 Copy of the most recent filed federal tax return with all schedules, including Schedule E—Supplement Income and Loss. Rental income for
qualifying purposes will be 75% of the gross rent reduced by the monthly debt service on the property, if applicable; or
 If rental income is not reported on Schedule E – Supplemental Income and Loss, provide a copy of the current lease agreement with either
bank statements or cancelled rent checks demonstrating receipt of rent.
Investment income:
 Copies of the two most recent investment statements or bank statements supporting receipt of this income.
Alimony, child support, or separation maintenance payments as qualifying income:*
 Copy of divorce decree, separation agreement, or other written legal agreement filed with a court, or court decree that states the amount
of the alimony, child support, or separation maintenance payments and the period of time over which the payments will be received, and
 Copies of your two most recent bank statements or other third-party documents showing receipt of payment.
*Notice: Alimony, child support, or separate maintenance income need not be revealed if you do not choose to have it considered for
repaying this loan.
Page 2 of 4
06/11
HARDSHIP AFFIDAVIT
(provide a written explanation with this request describing the specific nature of your hardship)
I am requesting review of my current financial situation to determine whether I qualify for temporary or permanent
mortgage relief options.
Date Hardship Began is:
I believe that my situation is:
Short-term (under 6 months)
Medium-term (6 – 12 months)
Long-term or Permanent Hardship (greater than 12 months)
I am having difficulty making my monthly payment because of reasons set forth below:
(Please check all that apply and submit required documentation demonstrating your hardship)
If Your Hardship is:
Unemployment
Then the Required Hardship Documentation is:
 No hardship documentation required
Underemployment

Income reduction (e.g., elimination of

overtime, reduction in regular working
hours, or a reduction in base pay)
Divorce or legal separation; Separation
of Borrowers unrelated by marriage,
civil union or similar domestic
partnership under applicable law




Death of a borrower or death of either

the primary or secondary wage earner
in the household

Long-term or permanent disability;
Serious illness of a borrower/coborrower or dependent family member
Disaster
(natural or man-made)
adversely impacting the property or
Borrower’s place of employment



No hardship documentation required, as long as you have submitted the
income documentation that supports the income described in the Required
Income Documentation section above
No hardship documentation required, as long as you have submitted the
income documentation that supports the income described in the Required
Income Documentation section above
Divorce decree signed by the court; OR
Separation agreement signed by the court; OR
Current credit report evidencing divorce, separation, or non-occupying
borrower has a different address; OR
Recorded quitclaim deed evidencing that the non-occupying Borrower or coBorrower has relinquished all rights to the property
Death certificate; OR
Obituary or newspaper article reporting the death
Doctor’s certificate of illness or disability; OR
Medical bills; OR
Proof of monthly insurance benefits or government assistance (if applicable)

Insurance claim; OR
Federal Emergency Management Agency grant or Small Business
Administration loan; OR
Borrower or Employer property located in a federally declared disaster area
Distant employment transfer

No hardship documentation required
Business Failure

Tax return from the previous year (including all schedules) AND
Proof of business failure supported by one of the following:
Bankruptcy filing for the business; or
Two months recent bank statements for the business account evidencing
cessation of business activity; or
Most recent signed and dated quarterly or year-to-date profit and loss
statement



Page 3 of 4
06/11
Borrower/Co-Borrower Acknowledgement and Agreement
1. I certify that all of the information in this Borrower Assistance Form is truthful and the hardship(s) identified
above has contributed to submission of this request for mortgage relief.
2. I understand and acknowledge that the Servicer, owner or guarantor of my mortgage, or their agent(s) may
investigate the accuracy of my statements, may require me to provide additional supporting documentation,
and that knowingly submitting false information may violate Federal and other applicable law.
3. I understand the Servicer will obtain a current credit report on all borrowers obligated on the Note.
4. I understand that if I have intentionally defaulted on my existing mortgage, engaged in fraud or
misrepresented any fact(s) in connection with this request for mortgage relief or if I do not provide all required
documentation, the Servicer may cancel any mortgage relief granted and may pursue foreclosure on my home
and/or pursue any available legal remedies.
5. I certify that my property has not received a condemnation notice.
6. I certify that I am willing to provide all requested documents and to respond to all Servicer communications in
a timely manner. I understand that time is of the essence.
7. I understand that the Servicer will use this information to evaluate my eligibility for available relief options and
foreclosure alternatives, but the Servicer is not obligated to offer me assistance based solely on the
representations in this document or other documentation submitted in connection with my request.
8. If I am eligible for a trial period plan, repayment plan, or forbearance plan, and I accept and agree to all terms
of such plan, I also agree that the terms of this Acknowledgment and Agreement are incorporated into such
plan by reference as if set forth in such plan in full. My first timely payment following my Servicer’s
determination and notification of my eligibility or prequalification for a trial period plan, repayment plan, or
forbearance plan (when applicable) will serve as acceptance of the terms set forth in the notice sent to me that
sets forth the terms and conditions of the trial period plan, repayment plan, or forbearance plan.
9. I agree that when the Servicer accepts and posts a payment during the term of any repayment plan, trial period
plan, or forbearance plan it will be without prejudice to, and will not be deemed a waiver of, the acceleration
of my loan or foreclosure action and related activities and shall not constitute a cure of my default under my
loan unless such payments are sufficient to completely cure my entire default under my loan.
10. I agree that any prior waiver as to my payment of escrow items to the Servicer in connection with my loan has
been revoked.
11. If I qualify for and enter into a repayment plan, forbearance plan, and trial period plan, I agree to the
establishment of an escrow account and the payment of escrow items if an escrow account never existed on
my loan.
12. I understand that the Servicer will collect and record personal information that I submit in this Borrower
Response Package and during the evaluation process, including, but not limited to, my name, address,
telephone number, social security number, credit score, income, payment history, and information about my
account balances and activity. I understand and consent to the Servicer’s disclosure of my personal
information and the terms of any relief or foreclosure alternative that I receive to any investor, insurer,
guarantor, or servicer that owns, insures, guarantees, or services my first lien or subordinate lien (if applicable)
mortgage loan(s) or to any HUD-certified housing counselor.
13. If I am eligible for foreclosure prevention relief under the federal Making Home Affordable Program, I
understand and consent to the disclosure of my personal information and the terms of any Making Home
Affordable Agreement by the Servicer to (a) the U.S. Department of the Treasury, (b) Fannie Mae and Freddie
Mac in connection with their responsibilities under the Homeowner Affordability and Stability Plan, and (c)
companies that perform support services in conjunction with Making Home Affordable.
14. I consent to being contacted concerning this request for mortgage assistance at any cellular or mobile
telephone number I have provided to the Lender. This includes text messages and telephone calls to my
cellular or mobile telephone.
______________________ __________ __________ ___________________________ __________
Borrower Signature
Date
Page 4 of 4
Co-Borrower Signature
Date
06/11
THIRD PARTY AUTHORIZATION AND RELEASE FORM
Lender Name: ____________________________________________________
Loan Number(s): __________________________________________________
Property Address: __________________________________________________
Authorized Third Party Information
Company Name: Short Sale Homes and affiliates.
Third Party Contact Name: Susana
Nunez
– 631.350.7536
Salvatore
Chierico
- 516.906.1935
Joe Lombardo
– 631.219.7000
Mathew Klein
– 631.619.5674
Mailing Address: 2929 Expressway Drive – Suite 310, Hauppauge, NY 11788
This Section Must Be Completed By The Customer(s).
I/We hereby authorize to discuss the above information on the referenced loan to the designated third
party or company. The password for this authorization if necessary is SHORT SALE.
Name (Print): ______________________________________
Signature: _________________________________________
SSN: _____________________________________________
Date: _____________________________________________
Name (Print): ______________________________________
Signature: _________________________________________
SSN: _____________________________________________
Date: _____________________________________________
AUTHORIZATION TO RELEASE INFORMATION
1st Loan#: _____________________________
2nd Loan#: _____________________________
I / We hereby authorize you to release to Short Sale Homes and affiliates:
Susana Nunez – 631.350.7536
Joe Lombardo
– 631.219.7000
Salvatore
Chierico
- 516.906.1935
Mathew Klein
–
631.619.5674
all information that they may require for the purpose of loss mitigation services. Authorization is specifically granted
to obtain any or all of the following items:
(a) Status of any and all accounts, including payoff amounts
(b) Verification of all employment
(c) Status of any and all judgments and liens
(d) Past Due Accounts and/or Accounts in Collections
(e) Credit History
(f) Request Payoff amount/Letter
I GRANT PERMISSION TO LENDER TO NEGOTIATE WITH SHORT SALE HOMES AND AFFILIATES ON MY BEHALF.
A photographic or carbon copy of this authorization being photographic or carbon copy of the signature(s) of the
undersigned shall be deemed equivalent to the original and this authorization remains in effect until notice of
cancellation is issued in writing.
Thank you,
_____________________________________
Print
_____________________________________
Signature
_____________________________________
Social Security #
_____________________________________
Date
____________________________________
Print
____________________________________
Signature
____________________________________
Social Security #
____________________________________
Date
Property Address: ___________________________________________________________________
PRELIMINARY CHECKLIST
Please provide all of the requested documents to your assigned negotiator WITHIN 3 DAYS;
1. INCOME DOCUMENTS:
‐ 2011 & 2012 or 2012 & 2013 tax returns + W‐2’s
‐ 2 most recent pay stubs
‐ 2 most recent award letters if you receive: social security, unemployment, a pension, workers
compensation, alimony, child support, an annuity, or a structured settlement.
2. BANK ACCOUNT INFORMATION:
‐ 2 most recent bank statements: All accounts; Front and back of each page. Please update every
30 days.
3. HARDSHIP LETTER: Please mention that you are requesting a Short Sale – (Sign and Date)
4. FINANCIAL WORKSHEET:
‐ Please complete the financial worksheet provided. Please include all expenses: cable,
telephone, food, gas, etc.
5. MOST RECENT MORTGAGE STATEMENTS:
‐ Please provide your most recent mortgage statements for all mortgages. If you do not have
a copy of your mortgage statement, then please provide any correspondence from the lender.
6. AUTHORIZATION FORMS – (Sign and Date)
7. ANY PAPERWORK SENT TO YOU BY EMAIL, FAX OR MAIL AS THEY APPLY TO ANY OF THE
FOLLOWING:
‐ Bankruptcy
‐ Foreclosure
‐ Late Mortgage Payments
‐ Late Insurance &/or Real Estate tax payments
‐ Any liens against the property other than a timely paid mortgage loan
8. COPY OF CURRENT UTILITY BILL
9. MISCELLANEOUS:
‐ For all rental properties, a copy of your most recent lease agreement
‐ 4506‐T (Enclosed)
‐ Agency Disclosure – Sign and Date
‐ RMA Affidavit – Complete, Sign and Date
Please Fax all Documents that apply to you directly to assigned negotiator.

Homeowner Listing Acknowledgement

Transcription

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