Loan modification enquiry form

Borrower name:
Co-borrower name:
Street:
City:
State:
 Zip:
Home phone:
Cell phone:
E-mail:
Lender:
Interest rate: Start date:
Payment: Balance:
Are taxes included in payment? Yes No If not, taxes:
Is insurance included in payment? Yes No If not, insurance:
Are you behind on payments? Yes No If yes, how many months:
Date of purchase: Approx. value LTV%
Borrower name:
Borrower net monthly income:
Co-borrower net monthly income:
Other income explain:
Notes/reasons for hardship