LMR Data Form

Please select the loan
advocate or referral source


Basic Info
Homeowner First Name
Homeowner Last Name
Co-owner First Name
Co-owner Last Name
File Type
Which services are requested?
How did you hear about us?
Phone number
 -    -    Ext #
Cell number  -    -  
Property Info
Property Address
Property City
Property State
Property Zip
Property Type
What is the current estimated value of your home?
How many years have you lived in the property?
Do you want to stay in this home?

 Housing Payment Increase
 Death of a significant other
 Death of a family member
 Damage to Property
 Military Service
 Business Failure
 Reduced Income
 Medical Bills
 Job Relocation
 Too Much Debt
 Other (Please Specify)
 Negative Equity
 Low Cash Reserves
Mortgage Info
Who is your 1st mortgage lender?
What is the estimated balance for the 1st mortgage?
What was the original amount of the 1st mortgage?
What is the payment of the 1st mortgage?
What is your monthly property tax payment?
What is your monthly property insurance payment?
Is there a 2nd lender?

Is the mortgage currently behind?

Have you received a notice of foreclosure?

Have you already received or tried to receive
a modification/ forbearance/work out from your bank?

Mortgage Notes