This form has been designed to help you collect the personal financial information you will need to review possible workout options with your lender, a counselor through the HOPE NOW Alliance, or a financial counselor of your choice. The following form does not collect any personal information that could be used to identify you. Nor will the information provided be retained by PMI or shared with any third party.

Once you've completed the form and selected "submit," you will be provided with a completed version of the form and have the option to print a copy from the website or have a copy of the form sent to you via email. If you choose the latter, you will be required to enter your email address.

Property Information

1. What was the original purchase price of your home?
$

2. Do you want to keep the property?
Yes No

3. Do you believe that you have the long-term ability to afford the property?
Yes No

4. Is your property currently listed for sale? (if no, skip to question 8).
Yes No

5. If yes, what is the list price
$

6. Have you received any offers?
Yes No

7. If yes, what was the amount of the offer you received?
$

8. Has your loan been referred for foreclosure?
Yes No

9. If yes, what is the foreclosure sale date?

Primary Borrower's Financial Information

Please note: totals below are rounded to the nearest dollar.

1. Net Monthly Salary/Wages (income AFTER taxes)
$

2. Unemployment Income (if any)
$

3. Disability Income (if any)
$

4. Social Security/Retirement Income (if any)
$

5. Pension Income (if any)
$

6. Alimony/Child Support Income (if any)
$

7. Rental Income (if any)
$

8. Other Income (if any)
$

9. Please describe the source of Other Income from number 8 (if any)

Total Net Monthly Income: $

Co-Borrower's Financial Information

Please note: totals below are rounded to the nearest dollar.

10. Net Monthly Salary/Wages (income AFTER taxes)
$

11. Unemployment Income (if any)
$

12. Disability Income (if any)
$

13. Social Security/Retirement Income (if any)
$

14. Pension Income (if any)
$

15. Alimony/Child Support Income (if any) (optional)
$

16. Rental Income (if any)
$

17. Other Income (if any)
$

18. Please describe the source of Other Income from number 17 (if any)

Total Net Monthly Income: $

Monthly Expenses: Long-Term Debt
(NOT deducted from your paycheck)

1. Mortgage Payment on your primary residence (include escrows)
$

2. 2nd or 3rd Mortgage Payments (if any) (include escrows)
$

3. Other Housing/Rent Payments (if any) (include escrows)
$

4. Payments on Home Equity Lines of Credit (if any)
$

5. Auto Loan Payments (if any)
$

6. Installment Loan Payments (if any)
$

7. Credit Card Payments (if any)
$

8. Alimony/Child Support Payments (if any)
$

Total Long-term Debt: $

Monthly Living Expenses:
(NOT deducted from your paycheck)

1. Utilities
$

2. Food
$

3. Homeowners Insurance (if not paid through escrow)
$

4. Property taxes (if not paid through escrow)
$

5. Auto Insurance (if any)
$

6. Gas/Maintenance/Parking (if any)
$

7. Health Insurance (if any)
$

8. Other Medical (if any)
$

9. Life Insurance (if any)
$

10. Club/Union/Association Dues (if any)
$

11. Charitable giving (if any)
$

12. Other Expenses (if any)
$ Please describe:

13. Other Expenses (if any)
$ Please describe:

14. Other Expenses (if any)
$ Please describe:

Total Living Expenses: $

Assets

1. Primary Residence (estimated value)
$

2. Source of Primary Residence estimate

3. Other Properties (estimated value)
$

4. Checking Account Balance
$

5. Savings Account Balance
$

6. 401K/IRA
$

7. Stocks/Bonds/CDs
$

8. Other Liquid Assets (if any)
$ Please describe:

9. Future Liquid Assets
$

Total Assets: $