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1003 Short Form for a Foreclosure Avoidance Loan.

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ALL FIELDS MUST BE FILLED OUT BEFORE YOU SUBMIT IT.

GENERAL INFORMATION

What's your name

Your address

City

State

County

Zip code

Daytime phone

E-mail address


PROPERTY INFORMATION

Value of home$

Mortgage balance$

Mortgage payment$

Interest rate%

2nd mortgage$

2nd mortgage interest rate%

Other liens

EMPLOYMENT INFORMATION

How long have you been at you present job

Are you self employd

DEFUALT INFORMATION

How many payments behind

How much time before auction sale