THE DELLUTRI LAW GROUP - War on the Home Front

Principal Office:
10491 Six Mile Cypress Pkwy; Suite 202
Ft. Myers, FL 33966
Phone: (877) 508-4848
Fax: (877) 508-4848
Email: [email protected]
HAMP-NPV Analysis Instructions & Checklist
Under the new Federal “Making Home Affordable” (HAMP) program, most lenders/servicers will require the
following documents as the minimum for considering a loan workout and we will need these documents in
order for us to complete and render the HAMP NPV Analysis for you.
Please fill out the attached Request for Modification & Affidavit and the Form 4506
completely and attach copies of the other items requested below.
REQUIRED DOCUMENTATION CHECKLIST
NOTE: Please checkmark each document line and submit this checklist with your documents.
It is VERY IMPORTANT THAT YOU FINISH THIS PART COMPLETELY!
[ ] Completed and Signed HAMP-NPV Analysis Client Agreement
[ ] Completed Client Information Form
[ ] Copy of recent mortgage statement for all lenders
[ ] Past 2 year’s tax return plus request for extension if applicable
[ ] Past year’s W-2’s if salaried or wage earner
[ ] Past two month’s paystubs (ex. 4 if paid bi-weekly, 8 if paid weekly) if salaried or wage earner
[ ] Past three months bank statements – checking and/or saving
[ ] Last six months Profit and Loss and/or Last two months Business Bank Accounts (if self-employed)
[ ] Copy of your driver’s license(s)
[ ] Completed Request for Modification & Affidavit form (attached)
[ ] Completed 4506-T – Request for Transcript of Tax Return (attached)
[ ] If receiving Social Security, Child Support or other types of income, please provide documentation to support
[ ] Recent copy of a utility bill to show that this is your primary residence
[ ] Copy of Homeowner’s Insurance policy and Property Tax bill – this is REQUIRED!
[ ] Summons Letter (First Page only, if applicable)
[ ] Foreclosure Complaint (if applicable)
[ ] Copy of any delinquency notices, notice of trustee’s sale, notice of default or any other documents that
have been received from your servicer or lender
CLIENT INFORMATION FORM
Date: _________________________
Referred by: ___________________________
Full Name: _______________________________________________________________________
Home Address: ____________________________________________________________________
City: __________________________ County: _____________________
Zip: ______________
Property Address (if different from home): ________________________________________________
City: __________________________ County: _____________________
Zip: ______________
E-Mail Address: ___________________________________________________________________
Home Phone: __________________________
Hours: ______________________________
Business/Cell Phone: __________________________ Hours: ______________________________
Spouse's Phone# (if different than above): ___________________________________
Spouse's Business/Cell Phone#: __________________________________________
Comments/Questions/Expecations:_____________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Home Affordable Modification Program (HAMP) NPV Analysis
Fee for Service Client Agreement
THIS AGREEMENT IS ENTERED INTO THIS _____ DAY OF _____________, 200____, BY AND BETWEEN
SHANNON M. HOUK, P.A. D/B/A CONSUMER LAW CENTER OF FLORIDA ("CLC"), WHOSE PRINCIPAL
ADDRESS IS 10491 SIX MILE CYPRESS PKWY. SUITE 202 FT. MYERS, FL 33966, AND _______________
________________________________________________("CLIENT"), WHOSE MAILING ADDRESS IS
__________________________________________________________________________________.
RECITALS
WHEREAS, CLIENT IS SEEKING ASSISTANCE WITH THE MITIGATION OF A HOME MORTGAGE(S); AND
WHEREAS, CLIENT HAS ATTEMPTED A LOAN MODIFICATION OR MITIGATION ON HIS/HER OWN AND
HAS ENCOUNTERED SUBSTANTIAL DIFFICULTIES IN THE PROCESS; AND
WHEREAS, CLIENT HAS DETERMINED THAT THEY ARE BETTER SERVED BY HIRING CLC TO ASSIST THEM IN
THE PROCESS; AND
WHEREAS, CLIENT UNDERSTANDS THAT THEY DO NOT NEED TO HIRE CLC TO ACHIEVE A LOAN
MODIFICATION BUT HAVE DECIDED THAT DOING SO IS IN THEIR OWN BEST INTERESTS; AND
WHEREAS, CLC AND THE CLIENT DESIRE TO ENTER INTO THIS “FEE FOR SERVICES AGREEMENT”
WHEREBY CLC CAN ASSIST CLIENT BY COLLECTING, ANALYZING AND SUBMITTING FINANCIAL AND
OTHER PERTINENT INFORMATION OF THE CLIENT FOR THE PURPOSES OF PROPOSING A LOAN
MODIFICATION WITH THE CLIENT’S SECURED LENDER/SERVICER; AND
WHEREAS, CLC MAY, FROM TIME TO TIME, WORK WITH THIRD PARTIES IN THE PROCESSING AND
SUBMISSION FUNCTIONS OF THE LOAN MODIFICATION PROCESS; AND
WHEREAS, THE PARTIES TO THIS AGREEMENT AGREE THAT IT IS IN THEIR MUTUAL INTEREST TO ABIDE
BY THE MANDATES OF THE LAWS OF THE STATE OF FLORIDA AND/OR ANY OTHER RELEVANT
JURISDICTION, AS WELL AS AVOID ANY UNCERTAINTY IN THE SERVICES BEING PROVIDED HEREUNDER,
CLC AND CLIENT MUTUALLY UNDERSTAND AND AGREE TO BE BOUND BY THE TERMS AND CONDITIONS
SET FORTH BELOW; AND
WHEREAS, CLIENT UNDERSTANDS AND ACKNOWLEDGES THAT THIS IS NOT A RETAINER AGREEMENT
AND CLC WILL NOT REPRESENT CLIENT IN ANY LEGAL MANNER OR PROVIDE CLIENT WITH ANY LEGAL
ADVICE.
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CLIENT INTIALS (_____) (______)
AGREEMENT
NOW THEREFORE, IN CONSIDERATION OF THE MUTUAL PROMISES, COVENANTS AND CONDITIONS SET
FORTH HEREIN, THE PARTIES AGREE AS FOLLOWS:
1. UPON EXECUTION OF THIS AGREEMENT, AND THE PROVISION OF THE SERVICES DELINEATED IN
PARAGRAPH THREE (3), CLC IS ENTITLED TO THE PAYMENT OF THE NON-REFUNDABLE HAMP
NPV ANALYSIS AND PROPOSAL FEE OF $550.00.
2. CLIENT UNDERSTANDS AND HEREBY ACKNOWLEDGES THAT THE HAMP NPV ANALYSIS FEE
COVERS INITIAL HARD COSTS INCURRED BY CLC AND/OR ITS AFFILIATES IN CONNECTION WITH
WORKING FOR CLIENT. CLIENT ACKNOWLEDGES THAT CLC WILL INCUR COSTS IMMEDIATELY
AND AS SUCH EARNS THE HAMP NPV ANALYSIS & PROPOSAL FEE FOR SERVICES RENDERED,
INCLUDING BUT NOT LIMITED TO, TIME, MATERIALS, LABOR, CREDIT REPORTS, RESEARCH,
SUBSCRIPTIONS TO SERVICES FOR ANALYSIS AND OTHER MISCELLANEOUS COSTS.
3. AS SUCH CLC, HEREBY COVENANTS TO DO THE FOLLOWING, WHEN APPLICABLE:
a. CONSULT WITH CLIENT TO AND REAFFIRM THE DETAILED FACTUAL HISTORY, ACCOUNTING
AND UNDERSTANDING OF THE CLIENT’S CURRENT FINANCIAL HARDSHIP AND CONDITION
AS IT RELATES TO THE CLIENT’S INABILITY TO PAY HIS/HER REGULAR MORTGAGE
PAYMENTS;
b. CONSULT WITH CLIENT TO UPDATE AND CONFIRM THE CAUSE OF CLIENT’S CURRENT
FINANCIAL CONDITION AND RE-ESTABLISH AND CONFIRM THE REASONS FOR THE CLIENT’S
INABILITY TO PAY HIS/HER REGULAR MORTGAGE PAYMENTS;
c. EXPLAIN AND EDUCATE THE CLIENT WITH REGARD TO THE LOAN MITIGATION PROCESS, AS
WELL AS REVIEW THE DETAILS OF AND ASSIST CLIENT WITH THE COMPLETION OF CLC’S
HAMP NPV ANALYSIS AND LOAN MODIFICATION PROPOSAL PACKAGE
d. REVIEW, UPDATE AND ANALYZE ALL OF THE CLIENT’S FINANCIAL INFORMATION, WHICH
WAS PREVIOULSY SUBMITTED TO THE CLIENT’S LENDER BY CLIENT INCLUDING BUT NOT
LIMITED TO THE FOLLOWING:
i. PAY STUBS, BANK STATEMENTS, INVESTMENT ACCOUNT STATEMENT, TAX
RETURNS, 1099, W-2 STATEMENTS, CAR PAYMENT STATEMENTS, UTILITY BILL
STATEMENTS, A DETAILED ACCOUNTING OF MONTHLY EXPENSES, AND ANY
AND ALL RELEVANT FINANCIAL INFORMATION;
ii. TO DETERMINE WHAT PROGRAM BEST SUIT CLIENT’S NEEDS, TO WIT: LOAN
MODIFICATION, LOAN FORBEARANCE, FORECLOSURE FORBEARANCE,
BANKRUPTCY, DEED IN LIEU OR SHORT SALE;
iii. THE CURSORY AND INFORMAL ANALYSIS OF THE VALUE OF THE CLIENT’S REAL
PROPERTY TO DETERMINE AN APPROXIMATE FAIR MARKET VALUE OF SAME;
iv. THE CLIENT’S COMPARATIVE AND FEASIBILITY ANALYSIS OF THE CURRENT FAIR
MARKET VALUE OF THE CLIENT’S REAL PROPERTY VERSUS THE OUTSTANDING
PRINCIPLE BALANCE OF THE MORTGAGE CURRENTLY ENCUMBERING SAME;
e. INPUT CLIENT’S FINANCIAL AND LOAN INFORMATION AND CONDUCT AN ANALYSIS ON
CLIENT’S ELIGIBILITY AND QUALIFICATION FOR A HAMP LOAN MODIFICATION UNDER THE
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CLIENT INTIALS (_____) (______)
MAKING HOME AFFORDABLE GUIDELINES PUBLISHED BY FANNIE MAE AND THE US
TREASURY DEPARTMENT.
f. PRESENT THE TERMS OF THE LOAN MODIFICATION/HAMP NPV ANALYSIS, LOAN
FORBEARANCE, RESTRUCTURED REPAYMENT, FORECLOSURE FORBEARANCE OR SHORT SALE
TO THE LENDER/SERVICER VIA CERTIFIED MAIL ON BEHALF OF THE CLIENT.
g. ONCE THE HAMP NPV ANALYSIS AND REPORT PACKAGE HAS BEEN COMPILED AND SENT TO
THE LENDER/SERVICER FOR EVALUATION, CLC’S SERVICES WILL HAVE BEEN DEEMED TO BE
COMPLETELY RENDERED IN FULL AND CLC WILL HAVE NO FURTHER OBLIGATION TO
REPRESENT CLIENT UNDER THIS AGREEMENT.
h. CLIENT UNDERSTANDS AND ACKNOWLEDGES THESE TERMS. CLIENT AND CLC MUTUALLY
AGREE THAT CLIENT MAY REQUEST TO HAVE CLC CONTINUE REPRESENTING OR ASSISTING
CLIENT FURTHER WITH THE LOAN MITIGATION PROCESS ONCE THE LENDER/SERVICER
RESPONDS TO THE REQUEST FOR A LOAN MODIFICATION BUT ANY SUCH FURTHER
REPRESENTATION OR ASSISTANCE FROM CLC FOR OR ON BEHALF OF CLIENT WILL REQUIRE
A NEW, SEPARATE RETAINER AGREEMENT AT THAT TIME.
i. IF CLIENT HAS BEEN REFERRED TO CLC BY ANOTHER ATTORNEY OR LAW FIRM, CLC WILL
NOT FURTHER REPRESENT CLIENT AFTER PERFORMING THE HAMP NPV ANALYSIS AND
PROPOSAL SERVICE. CLIENT SHOULD SEEK THE ADVICE AND SERVICES OF THE ATTORNEY OR
LAW FIRM THAT REFERRED CLIENT TO CLC. IN THE EVENT THAT CLIENT WISHES TO FURTHER
RETAIN CLC, CLC MAY CONSIDER FURTHER REPRESENTATION OF CLIENT IF THE REQUEST IS
RECEIVED BY BOTH CLIENT AND THE REFERRING ATTORNEY OR LAW FIRM.
4. CLIENT/HOMEOWNER RESPONSIBILITIES: CLIENT RESPONSIBILITIES: CLIENT AGREES TO THE
FOLLOWING AND UNDERSTANDS THAT FAILURE TO PERFORM THE CLIENT RESPONSIBILITIES
LISTED BELOW WILL RESULT IN FORFEITING ALL FEES TO BE PAID TO CLC REGARDLESS OF
OUTCOME:
a. CLIENT UNDERSTANDS THAT IF CONTACTED BY LENDER TO EXPLAIN TO THEM THAT CLIENT
HAS HIRED THE CONSUMER LAW CENTER OF FLORIDA FOR ASSISTANCE WITH THE LOAN
MODIFICATION EFFORTS.
b. CLIENT AGREES NOT TO COMPROMISE OR MAKE ANY AGREEMENT WITHOUT FIRST
NOTIFYING CLC OR CLIENT FORFEITS THE FEE(S) AS DESCRIBED ABOVE
c. CLIENT UNDERSTANDS THAT THEY ARE REQUIRED BY OUR OFFICE TO SAVE FUNDS THAT
WILL EQUAL THE AMOUNT OF CLIENT’S REGULAR MONTHLY MORTGAGE PAYMENT(S)
UNTIL CLIENT’S SITUATION IS RESOLVED. LIKEWISE, CLIENT IS TO SAVE ANY ADDITIONAL
FUNDS THAT MAY BE NEEDED IN THE MITIGATION PROCESS BY THE LENDER AND/OR CLC TO
EFFECT A SOLUTION.
d. CLIENT UNDERSTANDS THAT ANY CERTIFIED MAIL RECEIVED DURING OUR INVOLVEMENT
WITH THE CASE MUST BE CLAIMED AND FORWARDED TO CLC PROMPTLY. TIME IS OF THE
ESSENCE IN THESE MATTERS.
e. CLIENT UNDERSTANDS THEY ARE TO PROVIDE NECESSARY INFORMATION, OUTLINED ON
CLIENT RESPONSIBILITY FORM AND/OR DIRECTED BY CLC, IN A TIMELY MANNER. THE
INFORMATION REQUESTED COULD PLAY A CRITICAL ROLE IN THE OUTCOME OF THEIR
WORKOUT OPTIONS WITH THEIR MORTGAGE LENDER AND/OR OTHER PARTIES RELATED TO
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CLIENT INTIALS (_____) (______)
f.
THEIR MORTGAGE LOAN. FAILURE TO PROVIDE DOCUMENTATION WILL BE A BREACH OF
THIS AGREEMENT AND COULD RESULT IN THE LOSS OF THEIR HOME BY FORECLOSURE.
THE CLIENT/HOMEOWNER UNDERSTANDS THAT SHOULD THE CLIENT/HOMEOWNER
HINDER CLC IN ITS EFFORTS TO PERFORM THE ABOVE SERVICES, OR TERMINATE THIS
AGREEMENT BEFORE CLC IS ABLE TO COMPLETE THE SERVICES DELINEATED HEREIN, CLC
SHALL BE RELIEVED OF ANY FURTHER OBLIGATION WITH REGARD TO THE PERFORMANCE
OF THE SERVICES DELINEATED HEREIN.
5. THE CLIENT/HOMEOWNER, HEREBY AUTHORIZES CLC AND ITS ASSOCIATES TO SUBMIT ALL OF
CLIENT/HOMEOWNER’S RELEVANT INFORMATION TO LENDER IN AN EFFORT TO OBTAIN AN
OFFER TO MITIGATE TERMS/LOAN MODIFICATION FROM THE UNDERLYING MORTGAGE
HOLDER (S) DEEMED NECESSARY, AND ANY OTHER UNDERLYING LIEN HOLDERS REGARDING THE
FOLLOWING LENDERS AND PROPERTY:
a. PROPERTY ADDRESS: ______________________________________________________
b. LENDER/SERVICER NAME: __________________________________________________
6. CLIENT/HOMEOWNER HEREBY AUTHORIZES CLC AND ITS ASSOCIATES OR ANY FINANCIAL
SERVICES COMPANY, REAL ESTATE AGENCY, PERSONS, LENDER, INVESTOR, OR CREDIT
REPORTING AGENCY WHICH CLC SHALL DESIGNATE, TO OBTAIN ANY AND ALL INFORMATION
CONCERNING MY/OUR MORTGAGES, FINANCIAL OBLIGATIONS AND ALL OTHER CREDIT
MATTERS AS MAY BE REQUIRED IN CONNECTION WITH INTIATING AND/OR OBTAINING THE
MITIGATION OF TERMS/LOAN MODIFICATION FOR THE LOAN ENCUMBERING THE PROPERTY
NOTED ABOVE. ANY AND ALL PERSONAL INFORMATION PROVIDED WILL BE HELD UNDER STRICT
CONFIDENCE AND USED ONLY FOR THE PURPOSE OF NEGOTIATIONS WITH UNDERLYING LIEN
HOLDERS. CLIENT/HOMEOWNER HEREBY CONSENTS TO ALLOW CLC TO SHARE ANY AND ALL
INFORMATION REGARDING THIS MITIGATION OF TERMS TRANSACTION WITH ANY AND ALL
PARTIES CLC DEEMS NECESSARY
7. CLIENT/HOMEOWNER HEREBY AGREES THAT CLC AND ITS ASSOCIATES, EMPLOYEES,
MANAGERS, MEMBERS ETC., SHALL HAVE NO LIABILITY AND WILL BE HELD HARMLESS
REGARDING THIS TRANSACTION, AND THAT CLC SHALL ONLY BE ATTEMPTING TO OBTAIN AN
OFFER FROM THE LENDER IN THE HOPE OF ENABLING CLIENT/HOMEOWNER OR CLC‘S
AFFILIATES TO PERFORM NEGOTIATIONS WITH THE UNDERLYING LIEN HOLDERS WITH THE
INFORMATION PROVIDED BY THE PARTIES. ANY RELIEF OF DEBT FOR TAX ISSUES, DEFICIENCY
JUDGMENTS, OR ANY OTHER FINANCIAL IMPLICATIONS, HAVING TO DO WITH OR RESULTING
FROM A MITIGATION OF TERMS/ LOAN MODIFICATION (OR THE LACK THEREOF), SHOULD BE
DISCUSSED WITH A TAX PROFESSIONAL AND/OR ATTORNEY. FURTHERMORE, THE
UNDERSIGNED HEREBY UNDERSTANDS AND ACKNOWLEDGES CLC, ITS EMPLOYEES, MANAGERS,
MEMBER’S ASSOCIATES AND/OR AFFILIATES ARE NOT PROVIDING AND WILL NOT PROVIDE ANY
LEGAL ADVICE AND/OR LEGAL REPRESENTATION IN ASSOCIATION WITH THE HANDLING OF THIS
MATTER AND/OR THE SERVICES BEING RENDERED HEREUNDER.
8. WITH THE EXCEPTION OF THE OBLIGATIONS AND UNDERTAKINGS SET FORTH IN THIS
AGREEMENT, AND ONLY UPON COMPLETION OF ALL CLC’S OBLIGATIONS HEREUNDER,
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CLIENT INTIALS (_____) (______)
CLIENT/HOMEOWNER HEREBY REMISES, RELEASES, ACQUITS AND FOREVER DISCHARGES CLC,
ITS PARENTS, SUBSIDIARIES, AFFILIATES, OFFICES, DIRECTORS, AGENTS, EMPLOYEES,
PREDECESSORS, SUCCESSORS AND ASSIGNS FROM ANY AND ALL CLAIMS, DEFENSES, DAMAGES,
ACTIONS AND CAUSES OF ACTION, SUITS, SPECIALTIES, COVENANTS, CONTRACTS, AGREEMENTS
AND PROMISES, WHICH CLIENT/HOMEOWNER EVER HAD, NOW HAS, OR WHICH ANY PERSONAL
REPRESENTATIVE, HEIR, PREDECESSOR, SUCCESSOR OR ASSIGN OF CLIENT/HOMEOWNER, CAN,
SHALL OR MAY HAVE AGAINST CLC ITS PARENTS, SUBSIDIARIES, AFFILIATES, OFFICES,
DIRECTORS, AGENTS, EMPLOYEES, PREDECESSORS, SUCCESSORS AND ASSIGNS, WHETHER
KNOWN OR UNKNOWN, FOR, UPON OR BY REASON OF ANY MATTER CAUSE OR THING
WHATSOEVER, FROM THE BEGINNING OF TIME TO THE DATE OF THIS AGREEMENT. THIS
GENERAL RELEASE INCLUDES, WITHOUT LIMITATION, ANY CLAIM OR CAUSE OF ACTION THAT
WAS OR COULD HAVE BEEN ASSERTED IN THE ACTION AND ANY CLAIM OR OBLIGATION ARISING
UNDER, OUT OF OR IN CONNECTION WITH THE AGREEMENTS EXCEPT AS SPECIFICALLY
EXCEPTED ABOVE.
9. INDEMNIFICATION. CLIENT/HOMEOWNER HEREBY AGREES TO DEFEND AND HOLD HARMLESS
CLC FROM AND AGAINST ANY LIABILITY OF ANY NATURE WHATSOEVER ARISING OUT OF OR IN
CONNECTION WITH CLIENT/HOMEOWNER’S BREACH, IN WHOLE OR IN PART, OF THE
REPRESENTATIONS AND WARRANTIES HEREIN CONTAINED. THIS AGREEMENT CONSTITUTES
THE ENTIRE AGREEMENT BETWEEN THE PARTIES. CLC MAKES NO WARRANTY, EXPRESS OR
IMPLIED, AS TO THE FITNESS OF ANY RECOMMENDATION IT MAY MAKE TO
CLIENT/HOMEOWNER ARISING OUT OF THIS AGREEMENT. EXCEPT FOR CAUSE,
CLIENT/HOMEOWNER UNCONDITIONALLY WAIVES ANY RIGHT OF ACTION AGAINST CLC ITS
OFFICERS, DIRECTORS, EMPLOYEES, AGENTS, BROKERS AND ASSIGNS, AT LAW, EQUITY OR ANY
OTHER CAUSE OF ACTION FOR ANY REASON, DIRECTLY, INDIRECTLY OR PROXIMATELY BELIEVED
TO ARISE OUT OF THIS AGREEMENT, FOR ANY DAMAGES OF ANY NATURE WHATSOEVER THAT
CLIENT/HOMEOWNER MAY INCUR BY REASON OF CLIENT/HOMEOWNER FOLLOWING ANY
RECOMMENDATION OF CLC CLIENT/HOMEOWNER’S FAILURE TO FOLLOW ANY
RECOMMENDATION OF CLC WHETHER ANY SINGULAR, CONCURRENT OR SERIES OF
RECOMMENDATIONS ARE ACTED UPON OR NOT ACTED UPON IN WHOLE OR IN PART BY
CLIENT/HOMEOWNER. CLC AND ITS AGENTS, EMPLOYEES, REPRESENTATIVES, OFFICERS,
DIRECTORS, AND/OR ATTORNEYS MAKE NO STATED, SPECIFIC AND/OR IMPLIED WARRANTY OR
REPRESENTATION THAT A LOWER INTEREST RATE, MORTGAGE PAYMENT AND/OR BALANCE IS
GUARANTEED. NO SPECIFIC OUTCOME IS OR HAS BEEN REPRESENTED OR GUARANTEED IN ANY
MATTER. CLIENT/HOMEOWNER ALSO ACKNOWLEDGES THAT ANY LOAN MODIFICATION
ACHIEVED MAY BE NOTED BY THE LENDER (S) ON CLIENT/HOMEOWNER’S CREDIT REPORT AND
AFFECT CREDIT SCORES. CLIENT/HOMEOWNER FURTHER ACKNOWLEDGES AND AGREES TO
HOLD CLC AND ITS AGENTS, EMPLOYEES, REPRESENTATIVES, OFFICERS, DIRECTORS, AND/OR
ATTORNEYS COMPLETELY HARMLESS IN THE EVENT THAT CLIENT/HOMEOWNER’S POSITION IS
TOO SEVERE TO REMEDY AND CLIENT/HOMEOWNER’S MORTGAGE CANNOT BE MODIFIED
AND/OR CLIENT/HOMEOWNER’S LENDER (S) FOR WHATEVER REASON DO NOT AGREE TO
MODIFY CLIENT/HOMEOWNER’S MORTGAGE AND/OR CLIENT/HOMEOWNER’S HOME IS LOST IN
A FORECLOSURE OR TRUSTEE SALE FOR ANY REASON. ANY AND ALL DECISIONS MADE BY THE
LENDER (S) ARE TO BE CONSIDERED FINAL AND CLIENT/HOMEOWNER FULLY UNDERSTANDS
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CLIENT INTIALS (_____) (______)
THAT IF THE MODIFICATION IS ACCEPTED THAT CLIENT/HOMEOWNER IS BOUND BY THE NEW
TERMS AND ANY FAILURE TO COMPLY WITH THERE TERMS ARE SOLELY THE RESPONSIBILITY OF
THE CLIENT/HOMEOWNER. CLC AND ITS AGENTS, EMPLOYEES, REPRESENTATIVES, OFFICERS,
DIRECTORS, AND/OR ATTORNEYS WILL NO LONGER BE A PART OF THE MODIFICATION AND WILL
NOT BE RESPONSIBLE FOR ANY FURTHER ACTION, EITHER BY THE LENDER (S) OR
CLIENT/HOMEOWNER.
10. ENTIRE AGREEMENT. THIS AGREEMENT CONSTITUTES THE ENTIRE UNDERSTANDING BETWEEN
THE PARTIES WITH RESPECT TO THE CLAIMS ASSERTED IN THE ACTION. ALL PRIOR
NEGOTIATIONS AND UNDERSTANDINGS WHETHER VERBAL OR WRITTEN BETWEEN SAID
PARTIES AND THEIR AGENTS, EMPLOYEES AND REPRESENTATIVES ARE MERGED AND FULLY SET
FORTH HEREIN.
11. THE PARTIES HERETO AGREE TO EXECUTE ANY AND ALL ADDITIONAL DOCUMENTATION
REASONABLY NECESSARY TO COMPLETE OR EFFECTUATE THE TERMS OF THIS AGREEMENT.
12. COUNTERPART EXECUTION. THIS AGREEMENT MAY BE EXECUTED IN ONE OR MORE
COUNTERPARTS, EACH OF WHICH SHALL BE DEEMED AN ORIGINAL, BUT ALL OF WHICH
TOGETHER SHALL CONSTITUTE ONE AND THE SAME INSTRUMENT. THIS AGREEMENT MAY ONLY
BE MODIFIED OR AMENDED BY A WRITTEN AGREEMENT SIGNED BY A CORPORATE OFFICER OF
CLC AND YOU. IF YOU HAVE ANY QUESTIONS REGARDING THIS AGREEMENT, PLEASE CONTACT
YOUR LOAN MOD. AGENT.
13. ASSIGNMENTS. THE PARTIES HEREBY WARRANT THAT THEY HAVE NOT ASSIGNED OR
TRANSFERRED OR PURPORTED TO ASSIGN, TRANSFER OR SUBROGATE ANY CLAIMS OR RIGHTS
RELEASED HEREIN TO ANY OTHER PERSON OR ENTITY AND AGREE EACH TO HOLD THE OTHER
HARMLESS IN THE EVENT A FUTURE CLAIM IS BROUGHT BY ANY PURPORTED ASSIGNEE OF THE
PARTIES RELATED TO THE PROVISIONS OF THIS AGREEMENT.
14. ATTORNEY FEES. EACH OF THE PARTIES SHALL BEAR ITS OWN ATTORNEYS’ FEES AND COSTS
INCURRED IN CONNECTION WITH THE ABOVE REFERENCED SERVICES PROVIDED HEREUNDER,
ANY RESULTING LITIGATION, PRIOR NEGOTIATIONS AND THE PREPARATION OF THIS
AGREEMENT.
15. PREVAILING PARTY. IN ANY ACTION TO INTERPRET OR ENFORCE THIS AGREEMENT THE
PREVAILING PARTY SHALL BE ENTITLED TO RECOVER FROM THE OTHER PARTY ALL COSTS AND
EXPENSES INCLUDING REASONABLE ATTORNEYS’ FEES FOR TRIAL AND APPELLATE LEVELS.
16. GENDER. WHENEVER USED IN THIS AGREEMENT, THE SINGULAR SHALL INCLUDE THE PLURAL,
THE PLURAL SHALL INCLUDE THE SINGULAR, AND THE NEUTRAL GENDER SHALL INCLUDE THE
MALE AND FEMALE AS WELL AS A TRUST, COMPANY, CORPORATION, OR OTHER LEGAL
DOMESTIC OR FOREIGN ENTITY, ALL AS THE CONTEXT AND MEANING OF THIS AGREEMENT MAY
REQUIRE.
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CLIENT INTIALS (_____) (______)
17. HEADINGS. THE PARAGRAPH TITLES AND HEADINGS CONTAINED IN THIS AGREEMENT ARE
INSERTED AS A MATTER OF CONVENIENCE AND FOR EASE OF REFERENCE ONLY, AND SHALL BE
DISREGARDED FOR ALL OTHER PURPOSES INCLUDING THE CONSTRUCTION OR ENFORCEMENT
OF THIS AGREEMENT OR ANY OF ITS PROVISIONS.
18. TIME ESSENCE. TIME IS OF THE ESSENCE OF EVERY PROVISION OF THIS AGREEMENT THAT
SPECIFIES A TIME FOR PERFORMANCE.
19. FACSIMILE SIGNATURES. THE PARTIES MUTUALLY UNDERSTAND AND AGREE THAT SIGNATURE
OF A FACSIMILE COPY OF THIS AGREEMENT SHALL BE DEEMED AN ORIGINAL FOR ALL LAWFULLY
ENFORCEABLE PURPOSES.
20. AGREEMENT RECEIVED. BY VIRTUE OF THEIR SIGNATURES BELOW, CLIENT/HOMEOWNER
ACKNOWLEDGES THAT HE/SHE HAS READ, UNDERSTANDS AND AGREES TO EVERY TERM,
COVENANT AND CONDITION OF THIS AGREEMENT AND THAT HE/SHE HAS RECEIVED A TRUE
AND COMPLETE COPY HEREOF, EFFECTIVE THE DATE FIRST ABOVE WRITTEN.
21. GOVERNING LAW: THIS AGREEMENT SHALL BE CONSTRUED IN ACCORDANCE WITH AND
GOVERNED BY THE LAW OF FLORIDA AND VENUS FOR ALL SUITS, ACTIONS, NEGOTIATION ETC.
SHALL BE IN LEE COUNTY, FLORIDA.
CLIENT
CLIENT
___________________________________
[Signature]
________________________________
[Signature]
Name: _____________________________
[please print]
Name:___________________________
[please print]
Date: ______________________________
Date: ___________________________
SSN: _______________________________
SSN: ____________________________
SHANNON M. HOUK, P.A. D/B/A CONSUMER LAW CENTER OF FLORIDA
_____________________________________________
[Signature]
Printed Name: ___________________________
Date: _____________________________
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CLIENT INTIALS (_____) (______)
Title: ___________________________
LEGAL AUTHORIZATION FORM
THIS FORM WILL SERVE TO ACKNOWLEDGE THAT THE CAPTIONED MORTGAGOR HAS AUTHORIZED OUR
FIRM, CONSUMER LAW CENTER OF FLORIDA (CLC), TO ACT IN THEIR BEHALF TO RESOLVE THEIR
MORTGAGE PROBLEMS. THIS IS IN ACCORDANCE WITH TITLE 24 OF THE CFR 203.500 (HUD).
I HEREBY AUTHORIZE CLC TO VERIFY MY PAST PRESENT EMPLOYMENT EARNINGS RECORDS, BANK
ACCOUNTS, STOCK HOLDINGS, AND ANY OTHER ASSET BALANCES THAT ARE NEEDED TO PROCESS MY
MODIFICATION APPLICATION.
I FURTHER AUTHORIZE CLC TO ORDER A CONSUMER CREDIT REPORT AND VERIFY OTHER CREDIT
INFORMATION, INCLUDING PAST AND PRESENT MORTGAGE AND LANDLORD REFERENCES. IT IS
UNDERSTOOD THAT A COPY OF THIS FORM WILL ALSO SERVE AS AUTHORIZATION. THE INFORMATION
CLC OBTAINS IS ONLY TO BE USED IN THE PROCESSING OF MY APPLICATION FOR A LOAN
MODIFICATION.
BY INITIALING BELOW, I HEREBY ACKNOWLEDGE THAT I HAVE NOT BEEN ADVISED BY CLC, ANY OF ITS
AGENTS, AND/OR AFFILIATES TO FOREGO A MORTGAGE PAYMENT IN EXCHANGE FOR THE COST OF A
LOAN MODIFICATION PROGRAM.
I UNDERSTAND THAT A LOAN MODIFICATION REQUEST WILL NOT HALT ANY FORECLOSURE OR DEBT
COLLECTION PROCEEDINGS. SHOULD ANY AGENT, AFFILIATE, SALESPERSON, OR OTHERWISE, HAVE
INADVERTENTLY, ACCIDENTALLY, WILLFULLY, OR OTHERWISE, HAVE COMMUNICATED ANYTHING
CONTRARY TO THE AFOREMENTIONED TO ME, I UNDERSTAND THAT THEIR STATEMENTS ARE
ERRONEOUS, INCORRECT, AND NOT THE ADVICE OR RECOMMNDATION OF CLC.
I FURTHER ACKNOWLEDGE THAT NO GUARANTEES HAVE BEEN PROVIDED TO ME/US BY CLC AND/OR
ANY OF ITS AGENTS, AND/OR AFFILIATES AND A POSITIVE OUTCOME IS NOT GUARANTEED. I FURTHER
WARRANTY THAT I AM NOT IN THE PROCESS OF BANKRUPCY OF ANY TYPE.
CLIENT
CLIENT
___________________________________
[Signature]
________________________________
[Signature]
Name: _____________________________
[please print]
Name:___________________________
[please print]
Date: ______________________________
Date: ___________________________
SSN: _______________________________
SSN: ___________________________
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CLIENT INTIALS (_____) (______)
HOMEOWNER’S RIGHT OF CANCELLATION
YOU MAY CANCEL THIS AGREEMENT FOR SERVICES WITHOUT ANY PENALTY OR OBLIGATION WITHIN 3
BUSINESS DAYS FOLLOWING THE DATE THIS AGREEMENT IS SIGNED BY YOU.
THE CONSULTANT IS PROHIBITED BY LAW FROM ACCEPTING ANY MONEY, PROPERTY, OR OTHER FORM
OF PAYMENT FROM YOU UNTIL ALL PROMISED SERVICES ARE COMPLETE.
IF FOR ANY REASON YOU HAVE PAID THE CONSULTANT BEFORE CANCELLATION, YOUR PAYMENT MUST
BE RETURNED TO YOU NO LATER THAN 10 BUSINESS DAYS AFTER THE CONSULTANT RECEIVES YOUR
CANCELLATION NOTICE.
TO CANCEL THIS AGREEMENT
A SIGNED AND DATED COPY OF A STATEMENT THAT YOU ARE CANCELING THE AGREEMENT
SHOULD BE MAILED (POSTMARKED) OR DELIVERED TO:
CONSUMER LAW CENTER OF FLORIDA
10491 SIX MILE CYPRESS PKWY. SUITE 202
FT. MYERS, FL 33966
NO LATER THAN MIDNIGHT OF THIRD BUSINESS DAY FROM THE DAY YOU EXECUTE THIS AGREEMENT.
IMPORTANT: IT IS RECOMMENDED THAT YOU CONTACT YOUR LENDER OR MORTGAGE SERVICER
BEFORE SIGNING THIS AGREEMENT. YOUR LENDER OR MORTGAGE SERVICER MAY BE WILLING TO
NEGOTIATE A PAYMENT PLAN OR A RESTRUCTURING WITH YOU FREE OF CHARGE.
(F.S. 501.1377, CH. 2008-79 LAWS OF FLORIDA CH. 2008-79)
I/WE HEREBY ACKNOWLEDGE RECEIPT AND COPY OF THIS NOTICE OF OUR RIGHT TO CANCEL:
CLIENT
CLIENT
___________________________________
[Signature]
________________________________
[Signature]
Name: _____________________________
[please print]
Name:___________________________
[please print]
Date: ______________________________
Date: ___________________________
Page 9 of 10
CLIENT INTIALS (_____) (______)
AUTHORIZATION AND CONSENT TO DISCLOSE PERSONAL INFORMATION
I/We hereby give our consent to the Law Office of Shannon M. Houk, PA, d/b/a Consumer Law Center of
Florida and its associates or any financial services company, persons, real estate agency, escrow
company, attorney, lender, investor, or credit reporting agency which CLC and its associates shall
designate, to obtain any and all information concerning my/our mortgages, financial obligations and all
other credit matters as maybe required in connection with executing the sale of the property located at:
Client(s) Name:
Client(s) SS#(s)
Loan Number(s)
Property Address:
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
_____________________________________________________
_____________________________________________________
Therefore, we hereby authorize you to release such information concerning my/our mortgages, financial
obligations and all other credit matters deemed necessary with a real estate secured transaction.
Furthermore, this authorization shall serve to confirm that I have retained the Consumer Law Center of
Florida’s services and hereby direct that all phone calls are to be made directly to CLC.
The Law Office telephone number for your reference is 877-508-4848
A photographic, fax, or carbon copy of this authorization may be deemed the equivalent of the original
and may be used as a duplicate original. As time is of the essence, your prompt reply will be helpful for
completing my real estate transaction
CLIENT
CLIENT
___________________________________
[Signature]
________________________________
[Signature]
Name: _____________________________
[please print]
Name:___________________________
[please print]
Date: ______________________________
Date: ___________________________
SSN: _______________________________
SSN: ____________________________
Page 10 of 10
CLIENT INTIALS (_____) (______)
Print Form
Making Home Affordable Program
Request For Modification and Affidavit (RMA)
REQUEST FOR MODIFICATION AND AFFIDAVIT (RMA) page 1
Loan I.D. Number____________________________________
COMPLETE ALL THREE PAGES OF THIS FORM
Servicer ____________________________________
BORROWER
CO-BORROWER
Borrower’s name
Social Security number
Co-borrower’s name
Date of birth
Social Security number
Date of birth
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
I want to:
Keep the Property
Sell the Property
The property is my:
Primary Residence
Second Home
Investment
The property is:
Owner Occupied
Renter Occupied
Vacant
Mailing address
Property address (if same as mailing address, just write same)
E-mail address
Is the property listed for sale?
Yes
No
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
Have you contacted a credit-counseling agency for help
Yes
No
If yes, please complete the following:
Counselor’s Name: _________________________________________
Agency Name: ____________________________________________
Counselor’s Phone Number: __________________________________
Counselor’s E-mail: ________________________________________
Who pays the real estate tax bill on your property?
I do
Lender does
Paid by condo or HOA
Are the taxes current?
Yes
No
Condominium or HOA Fees
Yes
No $ __________________
Paid to: _________________________________________________
Who pays the hazard insurance premium for your property?
I do
Lender does
Paid by Condo or HOA
Is the policy current?
Yes
No
Name of Insurance Co.: ______________________________________
Insurance Co. Tel #: _________________________________________
Have you filed for bankruptcy?
Yes
Has your bankruptcy been discharged?
No
Yes
If yes:
No
Chapter 7
Chapter 13
Filing Date:_________________________
Bankruptcy case number _________________________________
Additional Liens/Mortgages or Judgments on this property:
Lien Holder’s Name/Servicer
Balance
Contact Number
Loan Number
HARDSHIP AFFIDAVIT
I (We) am/are 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: unemployment,
underemployment, 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.
Other:
Explanation (continue on back of page 3 if necessary): __________________________________________________________________________
______________________________________________________________________________________________________________________
page 1 of 3
REQUEST FOR MODIFICATION AND AFFIDAVIT (RMA) page 2
COMPLETE ALL THREE PAGES OF THIS FORM
INCOME/EXPENSES FOR HOUSEHOLD1
Monthly Household Income
Number of People in Household:
Monthly Household Expenses/Debt
Household Assets
Monthly Gross Wages
$
First Mortgage Payment
$
Checking Account(s)
$
Overtime
$
Second Mortgage Payment
$
Checking Account(s)
$
Child Support / Alimony /
Separation2
$
Insurance
$
Savings/ Money Market
$
Social Security/SSDI
$
Property Taxes
$
CDs
$
Other monthly income from
pensions, annuities or
retirement plans
$
Credit Cards / Installment
Loan(s) (total minimum
payment per month)
$
Stocks / Bonds
$
Tips, commissions, bonus
and self-employed income
$
Alimony, child support
payments
$
Other Cash on Hand
$
$
Other Real Estate
(estimated value)
$
$
Rents Received
Net Rental Expenses
Unemployment Income
$
HOA/Condo Fees/Property
Maintenance
$
Other _____________
$
Food Stamps/Welfare
$
Car Payments
$
Other _____________
$
Other (investment income,
royalties, interest, dividends
etc.)
$
Other ________________
_____________________
$
Do not include the value of life insurance or
retirement plans when calculating assets (401k,
pension funds, annuities, IRAs, Keogh plans, etc.)
Total (Gross Income)
$
Total Debt/Expenses
$
Total Assets
$
INCOME MUST BE DOCUMENTED
1
Include combined income and expenses from the borrower and co-borrower (if any). If you include income and expenses from a household
member who is not a borrower, please specify using the back of this form if necessary.
2You are not required to disclose Child Support, Alimony or Separation Maintenance income, unless you choose to have it considered by your servicer.
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 or surname if you have made this request for a loan modification in person. If you do not wish
to furnish the information, please check the box below.
BORROWER
I do not wish to furnish this information
CO-BORROWER
I do not wish to furnish this information
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Race:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Race:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Sex:
Female
Male
Sex:
Female
Male
To be completed by interviewer
This request was taken by:
Face-to-face interview
Mail
Telephone
Internet
Name/Address of Interviewer’s Employer
Interviewer’s Name (print or type) & ID Number
Interviewer’s Signature
Date
Interviewer’s Phone Number (include area code)
page 2 of 3
REQUEST FOR MODIFICATION AND AFFIDAVIT (RMA) page 3
COMPLETE ALL THREE PAGES OF THIS FORM
ACKNOWLEDGEMENT AND AGREEMENT
1. That all of the information in this document is truthful and the event(s) identified on page 1 is/are the reason that I
need to request a modification of the terms of my mortgage loan, short sale or deed-in-lieu of foreclosure.
2. I understand that the Servicer, the U.S. Department of the Treasury, or their agents may investigate the accuracy of my
statements and may require me to provide supporting documentation. I also understand that knowingly submitting false
information may violate Federal law.
3. I understand the Servicer will pull 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 document, the Servicer may cancel any Agreement under Making Home Affordable and
may pursue foreclosure on my home.
5. That: my property is owner-occupied; I intend to reside in this property for the next twelve months; I have not received
a condemnation notice; and there has been no change in the ownership of the Property since I signed the documents
for the mortgage that I want to modify.
6. I am willing to provide all requested documents and to respond to all Servicer questions in a timely manner.
7. I understand that the Servicer will use the information in this document to evaluate my eligibility for a loan modification
or short sale or deed-in-lieu of foreclosure, but the Servicer is not obligated to offer me assistance based solely on
the statements in this document.
8. I am willing to commit to credit counseling if it is determined that my financial hardship is related to excessive debt.
9. 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, (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 that perform support services in
conjunction with Making Home Affordable; and (e) any HUD-certified housing counselor.
Borrower Signature
Date
Co-Borrower Signature
Date
HOMEOWNER’S HOTLINE
If you have questions about the program that your servicer cannot answer or need further counseling,
you can call the Homeowner’s HOPE™ Hotline at 1-888-995-HOPE (4673). The Hotline can help with questions about
NOTICE TO BORROWERS
Be advised that by signing this document you understand that any documents and information you submit to your servicer in connection with the Making
Home Affordable Program are 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, expenses, or assets 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. By signing this document you certify, represent and agree that:
“Under penalty of perjury, all documents and information I have provided to Lender in connection with the Making Home
Affordable Program, including the documents and information regarding my eligibility for the program, are true and correct.”
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.
page 3 of 3
7
TLS, have you
transmitted all R
text files for this
cycle update?
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 4506, PAGE 1 of 2
MARGINS: TOP 13 mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD to HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216 mm (81⁄ 2 ") 3 279 mm (11")
PERFORATE: NONE
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
Date
Form
Date
Signature
O.K. to print
Revised proofs
requested
Request for T ranscript of T ax Retur n
4506-T
©
(Rev. January 2008)
Department of the Treasury
Internal Revenue Service
Action
©
Do not sign this form unless all applicable lines have been completed.
Read the instructions on page 2.
Request may be rejected if the form is incomplete, illegible, or any required
line was blank at the time of signature.
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 also call 1-800-829-1040 to
order a transcript. 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 or
employer identification number (see instructions)
2a If a joint return, enter spouse’s name shown on tax return
2b Second social security number if joint tax return
3
Current name, address (including apt., room, or suite no.), city, state, and ZIP code
4
Previous address shown on the last return filed if different from line 3
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. The IRS has no control over what the third party does with the tax information.
Caution: DO NOT SIGN this form if a third party requires you to complete Form 4506-T, and lines 6 and 9 are blank.
6
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. ©
a Return Transcript, which includes most of the line items of a tax return as filed with the IRS. 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 is a combination of line item information and later adjustments to the account. Available for current year
and 3 prior tax years. Most requests will be processed within 30 calendar days
7
Verification of Nonfiling, which is proof from the IRS that you did not file a return for the year. Most requests will be processed
within 10 business days
8
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 2006, filed in 2007, will not be available from the IRS until 2008. 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.
/
/
/
/
/
/
/
/
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.
Telephone 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. 1-2008)