Dear Homeowner,
Thank you for requesting assistance for foreclosure prevention by RIHousing.
To complete your request, you must first fill out our Financial Information Package and send us the
required documents which are needed to process your request for assistance. Please use the
required documents checklist attached. Please do not send original documents. You can send the
completed application and required documents packet to us by facsimile, mail, or e-mail.
You may also simply drop them off at our office:
RIHousing HelpCenter
44 Washington Street
Providence, RI 02903
Fax: 401-450-1373
Please return your financial information packet as soon as possible, as this is a time-sensitive
Once we have received your application packet, you will be assigned to a HUD Counselor. The HUD
Counselor will follow up with you to review your options and/or discuss additional information that
may be needed.
If you have any questions or need any assistance with the application, please contact us at:
(401) 457-1130.
TTY: (401) 450-1394.
Thank you for reaching out to the RIHousing HelpCenter.
RIHousing HelpCenter
NOTE: If you have an impairment, disability, language barrier, or otherwise require an alternative means of
completing this form or accessing information about our housing counseling program, please inform our
housing counselor program staff so alternative accommodations may be arranged.
Please DO NOT Send Originals
Single-sided Copies Please
1. Most recent pay stubs 30 consecutive days of pay stubs for all borrowers/ contributors (person
other than mortgage holder). Contributors must send signed and dated contribution amount letter.
2. Proof of all other sources of income for borrowers/contributors (SSI, SSDI, child support, rental
income etc.) Most recent benefit award letter for all SSI, SSDI, TDI and/or Unemployment income
being received. If receiving Government Assistance (ex. SNAP), please include the Quarterly Benefit
Statement. Rental income leases.
3. Two years of recent Federal Tax Returns signed tax returns for the last two years (personal and
business) with all schedules and W-2’s. If no tax returns, then a letter, signed and dates, explaining
why no taxes were filed.
4. Two months of recent bank statements from all saving & checking accounts, all pages, front and
back, for the last two months (personal and business). Transaction history is not acceptable.
5. Self-employed borrowers must provide most recent quarterly or year-to-date Profit & Loss
Statement. Statement must be signed and dated.
6. Most recent utility bill at least one gas, electric, or cable bill.
7. Most recent mortgage statement with loan number and lender/servicer contact information.
8. Delinquency letters/notices mediation, conciliation, tax sale, or foreclosure notices, if applicable.
9. Property tax bill only if current mortgage payment does not include an escrow payment.
10. Homeowners Insurance Policy declaration page(s). Only if current mortgage payment does not
include and escrow payment.
11. Bankruptcy discharge notice, if applicable.
12. Court Orders Final Divorce Decree, Alimony, and Child support payments, if applicable
13. Homeowners Association Fee Statement, if applicable.
14. Help Center Authorization, Dodd Frank, 4506T, Homeowner/Counselor Agreement, and Consent
to the Use of Tax Return Information Forms – signed and dated by all borrowers (pgs. 7-13)
15. Hardship Letter signed and dated by all borrowers (pg. 6).
16. Copy of Drivers License or State ID
Page 1/13
Borrower Information
Number of people in household.
Financial Information
Relationship to Applicant
Borrower’s Name
Social Security Number
- -
Date of Birth (month/day/year)
/ /
Social Security Number
- -
Date of Birth (month/day/year)
/ /
Primary Phone Number With Area Code
( ) -
Secondary Phone Number
Email Address
Mailing Address
Present Address (If Same As Mailing Address, Write Same)
Married Unmarried (includes single, divorced, widowed) Separated
Yrs School
Military Status: N/A Active Veteran
Are you a US Citizen? Yes No
Are you a Permanent Resident Alien? Yes No
Page 2/13
Employment Information
Employed Unemployed Self-employed
Employed Unemployed Self-employed
Work Phone Number With Area Code
( ) -
Work Phone Number With Area Code
( ) -
# Of Years at Current or Most Recent Job
# Of Years at Current or Most Recent Job
Property Information
Single Family
Multi-family (1-4 Units)
Property Purchase Date
Property Condition:
Excellent Good
Estimated Property Value
I want to: Keep the Property Sell the Property
Is the property listed for sale?Yes No
For Sale by Owner? Yes No
Agent’s Name:
Agent’s Phone Number:
Have you received an offer on the property? Yes No
Date of Offer Amount of Offer $
Have you received a foreclosure sale date? Yes
Foreclosure Date No
Have you received a notice of Mediation or Conciliation?
Yes No
Have you filed for bankruptcy? Yes No
If yes: Chapter 7 Chapter 13 Filing Date:
Has your bankruptcy been discharged? Yes
No Bankruptcy Case Number: Attorney:
Page 3/13
Mortgage Information
First Mortgage Lender/Servicer Name
First Mortgage Loan Number
Interest Rate
Monthly Payment Amount (Principal, Interest, Taxes, and Insurance)
Monthly Mortgage Insurance Payment (If Applicable)
Are you current on your First Mortgage? Yes No
If yes, are you in danger of falling delinquent? Yes No
Has your mortgage ever been modified or have you entered into a forbearance plan? Yes
Have you received Hardest Hit Funds in the past: Yes No
Who pays the real estate tax bill on your property?
Who pays hazard insurance policy for your property?
Are the taxes current? Yes No
Is the policy current? Yes No
Condominium or HOA Fee: Yes $ No
Paid to:
Do you have a second mortgage/ Home Equity Loan? Yes No
If yes, provide detail below.
Second Mortgage Lender/Servicer Name
Second Mortgage Loan Number
Interest Rate
Monthly Payment Amount (Principal, Interest, Taxes, and Insurance)
Monthly Mortgage Insurance Payment (If Applicable)
List other Liens/Mortgages or Judgments on this property, please name the person(s), company or firm and their telephone numbers.
Lien Holder’s Name/Servicer Balance
Contact Number Loan Number
Page 4/13
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 or grant in person. If you do not wish to furnish the information, please check the box below.
I do not wish to furnish this information
I do not wish to furnish this information
Hispanic or Latino Not Hispanic or Latino
Hispanic or Latino Not Hispanic or Latino
American Indian or Alaska Native
Asian Black or African American
Native Hawaiian or Other Pacific Islander White
American Indian or Alaska Native
Asian Black or African American
Native Hawaiian or Other Pacific Islander White
Female Male
Female Male
Page 5/13
Monthly Income/Expenses For Household
Page 6/13
Hardship Affidavit
Explanation (Required):
If additional space is needed for Explanation, please include an additional page.
HelpCenter Authorization / Disclosure
I understand that RIHousing provides foreclosure prevention counseling (“Counseling”) and I request that RIHousing provide me
such assistance. An overview of the range of Counseling services that I am entitled to receive is set forth on Attachment A. I
understand that I have a choice with respect to HUD-approved counseling agencies, and I am not required to use RIHousing to
provide counseling.
I authorize RIHousing to contact my mortgage lender or servicer (collectively,
the “Mortgagee”) on my behalf regarding any loan secured by my property located at
the “Loan”) and to obtain from such Mortgagee any information regarding my Loan that RIHousing deems necessary to provide
the Counseling.
I have provided RIHousing information regarding my personal finances and authorize RIHousing to obtain a credit report on me
in order to provide the Counseling (this information, along with the information obtained from the Mortgagee, the “Financial
I understand and agree that RIHousing will use the Financial Information to evaluate my options regarding the Loan and to develop an
action plan consisting of recommendations for handling of the Loan and my finances, which will be presented to me.
I authorize RIHousing to share the Financial Information with the Mortgagee and to discuss the Loan and the Financial Information
with the Mortgagee. I understand that I may or may not be present during these discussions.
I may be referred to other housing services of RIHousing or another agency or agencies as appropriate that may be able to assist with
particular issues that have been identified. I understand that I am not obligated to use any of the services offered to me. I understand
that RIHousing provides a variety of lending and mortgage products, including: mortgage loans to low- and moderate-income
homebuyers and homeowners; home repair loans; septic system replacement loans; sewer tie- in loans; lead abatement loans; and
loans for home modification to assist disabled residents. The loans described above may also be originated by participating lenders or
third-party brokers, who are compensated by RIHousing for their origination services. I further understand that I am not obligated to
use or receive any other products or services from RIHousing or its participating lenders or brokers.
RIHousing offers a variety of mortgage-related services, including first-time homebuyer training and landlord training. I
understand that I am not obligated to use or receive any of these other services from RIHousing. If I already receive mortgage-
related services from RIHousing, I understand that I am not obligated to use RIHousing for Counseling services and may choose
from among HUD-approved housing counseling agencies.
I understand that RIHousing’s HelpCenter is a U.S. Department of Housing and Urban Development (“HUD”) certified counseling
agency and that, as such, RIHousing may receive federal funds from HUD or another funding source. Due to the nature of these
relationships, RIHousing may be required to make information relating to my loan, my financial information, and any other information
in my counseling file available to HUD or another funding source for program monitoring and compliance purposes. Further, I authorize
RIHousing, HUD, or any other funding source to contact me for program evaluation purposes.
I understand that a counselor may answer questions and provide information, but not provide legal advice. Counseling is not a
substitute for legal advice. If I want legal advice, I will be referred for appropriate assistance.
I acknowledge that I have received a copy of RIHousing’s Privacy Policy.
Loan Number
Name (printed) Signature Date
Last 4 Social Security Number
Signature Date
Page 7/13
click to sign
click to edit
click to sign
click to edit
Attachment A
Outline of Counseling Services
The following is an outline of the Counseling Services which are provided as part of this program.
1. The Intake Counselor reviews the homeowner’s financial situation. In order to complete this review, the counselor obtains a credit
report and collects income and expense documentation. This allows the Counselor to analyze the homeowner’s financial capacity
and determine if there is a hardship.
2. If, based upon this intake and initial file, mortgage fraud is suspected, we may refer the case to the Consumer Protection Division
of the Rhode Island Attorney General and the Rhode Island Department of Business Regulation.
3. Based on the review of the information developed through the intake, and any supplemental information submitted, we will work
with you to develop an action plan to seek relief, including steps you may need to take to control household expenses, and any
additional documents you must submit.
4. We will review your situation to determine potential eligibility for loss mitigation options using investors and lenders
proprietary programs.
5. If appropriate, we will inform you of other local programs and resources that may be available to assist you. Examples of
these services and programs include Food Stamps, Heating Assistance programs, Community Action Program agencies,
alternative housing options, financial management assistance (through Money Management International), legal assistance
(through Rhode Island Legal Services or the Rhode Island Bar Association), and the like.
6. If appropriate, we will assist you in preparing a hardship letter for submission to your lender/servicer to support your request for a
work out option. We will maintain communication with you and your lender/servicer to monitor the status of your loan workout
request and to ensure that all necessary documentation is submitted on time.
7. We will review and evaluate any written work out proposal you receive from your lender/servicer to help you determine whether
to accept the proposal.
8. We will ask you whether you have been offered questionable mortgage foreclosure prevention assistance, including proposals
that guarantee a successful outcome; require payment in advance of the provision of assistance; require that you stop making
mortgage payment or require redirection of your mortgage payments to someone other than your lender/servicer; involve signing
over title to your home to a third-party. If we suspect that improper practices are present we will report the practices to the
Consumer Division of the Rhode Island Attorney General and the Loan Modification Scam alert website.
Page 8/13
Page 9/13
Catalog Number 72627P
4506-C (9-2020)
Form 4506-C
(September 2020)
Department of the Treasury - Internal Revenue Service
IVES Request for Transcript of Tax Return
OMB Number
Do not sign this form unless all applicable lines have been completed.
Request may be rejected if the form is incomplete or illegible.
For more information about Form 4506-C, visit and search IVES.
1a. Name shown on tax return (if a joint return, enter the name shown
1b. First social security number on tax return, individual taxpayer identification
number, or employer identification number (see instructions)
2a. If a joint return, enter spouse’s name shown on tax return 2b. Second social security number or individual taxpayer identification number
if joint tax return
3. Current name, address (including apt., room, or suite no.), city, state, and ZIP code (see instructions)
4. Previous address shown on the last return filed if different from line 3 (see instructions)
5a. IVES participant name, address, and SOR mailbox ID
5b. Customer file number (if applicable) (see instructions)
Caution: This tax transcript is being sent to the third party entered on Line 5a. Ensure that lines 5 through 8 are completed before signing. (see instructions)
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. A tax return transcript does not reflect changes
made to the account after the return is processed. Transcripts are only available for the following returns: Form 1040 series, Form 1065, Form
1120, Form 1120-A, Form 1120-H, Form 1120-L, and Form 1120S. Return transcripts are available for the current year and returns processed
during the prior 3 processing years
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
Record of Account, which provides the most detailed information as it is a combination of the Return Transcript and the Account Transcript.
Available for current year and 3 prior tax years
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
2016, filed in 2017, will likely not be available from the IRS until 2018. If you need W-2 information for retirement purposes, you should contact the
Social Security Administration at 1-800-772-1213
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.
Year or period requested. Enter the ending date of the tax year or period using the mm/dd/yyyy format (see instructions)
/ / / / / / / /
Caution: Do not sign this form unless all applicable lines have been completed.
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, at least one spouse must sign. If signed by a corporate officer, 1 percent or more shareholder, partner,
managing member, 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-C on behalf of the taxpayer. Note: This form must be received by IRS within 120 days of the signature date.
Signatory attests that he/she has read the attestation clause and upon so reading declares that he/she has the authority to sign the Form 4506-C.
See instructions.
Signature (see instructions)
Date Phone number of taxpayer on line 1a or 2a
Print/Type name
Title (if line 1a above is a corporation, partnership, estate, or trust)
Spouse’s signature Date
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
Print/Type name
Catalog Number 72627P
4506-C (9-2020)
Instructions for Form 4506-C, IVES Request for Transcript of Tax Return
Section references are to the Internal Revenue
Code unless otherwise noted.
Future Developments
For the latest information about Form 4506-C and
its instructions, go to and search
IVES. Information about any recent developments
affecting Form 4506-C (such as legislation
enacted after we released it) will be posted on that
What's New. Form 4506-C was created to be
utilized by authorized IVES participants to order
tax transcripts with the consent of the taxpayer.
General Instructions
Caution: Do not sign this form unless all
applicable lines have been completed.
Designated Recipient Notification. Internal
Revenue Code, Section 6103(c), limits disclosure
and use of return information received pursuant to
the taxpayer’s consent and holds the recipient
subject to penalties for any unauthorized access,
other use, or redisclosure without the taxpayer’s
express permission or request.
Taxpayer Notification. Internal Revenue Code,
Section 6103(c), limits disclosure and use of return
information provided pursuant to your consent and
holds the recipient subject to penalties, brought by
private right of action, for any unauthorized
access, other use, or redisclosure without your
express permission or request.
Purpose of form. Use Form 4506-C to request
tax return information through an authorized IVES
participant. You will designate an IVES participant
to receive the information on line 5a.
Note: If you are unsure of which type of transcript
you need, check with the party requesting your tax
Where to file. The IVES participant will fax Form
4506-C with the approved IVES cover sheet to
their assigned Service Center.
Chart for ordering transcripts
If your assigned
Service Center is:
Fax the requests with
the approved
coversheet to:
Austin Submission
Processing Center
Austin IVES Team
Fresno Submission
Processing Center
Fresno IVES Team
Kansas City Submission
Processing Center
Kansas City IVES
Ogden Submission
Processing Center
Ogden IVES Team
Specific Instructions
Line 1b. Enter the social security number (SSN)
or individual taxpayer identification number (ITIN)
for the individual listed on line 1a, or enter the
employer identification number (EIN) for the
business listed on line 1a.
Line 3. Enter your current address. If you use a
P.O. box, include it on this line.
Line 4. Enter the address shown on the last return
filed if different from the address entered on line 3.
Note: If the addresses on lines 3 and 4 are
different and you have not changed your address
with the IRS, file Form 8822, Change of Address,
or Form 8822-B,Change of Address or
Responsible Party — Business, with Form 4506-C.
Line 5b. Enter up to 10 numeric characters to
create a unique customer file number that will
appear on the transcript. The customer file number
cannot contain an SSN, ITIN or EIN. Completion
of this line is not required.
Note. If you use an SSN, name or combination of
both, we will not input the information and the
customer file number will reflect a generic entry of
"9999999999" on the transcript.
Line 8. Enter the end date of the tax year or
period requested in mm/dd/yyyy format. This may
be a calendar year, fiscal year or quarter. Enter
each quarter requested for quarterly returns.
Example: Enter 12/31/2018 for a calendar year
2018 Form 1040 transcript.
Signature and date. Form 4506-C must be
signed and dated by the taxpayer listed on line 1a
or 2a. The IRS must receive Form 4506-C within
120 days of the date signed by the taxpayer or it
will be rejected. Ensure that all applicable lines,
including lines 5a through 8, are completed before
You must check the box in the signature
area to acknowledge you have the authority
to sign and request the information. The form
will not be processed if unchecked.
Individuals. Transcripts listed on on line 6 may be
furnished to either spouse if jointly filed. Only one
signature is required. Sign Form 4506-C exactly
as your name appeared on the original return. If
you changed your name, also sign your current
Corporations. Generally, Form 4506-C can be
signed by:
(1) an officer having legal authority to bind the
corporation, (2) any person designated by the
board of directors or other governing body, or (3)
any officer or employee on written request by any
principal officer and attested to by the secretary or
other officer. A bona fide shareholder of record
owning 1 percent or more of the outstanding stock
of the corporation may submit a Form 4506-C but
must provide documentation to support the
requester's right to receive the information.
Partnerships. Generally, Form 4506-C can be
signed by any person who was a member of the
partnership during any part of the tax period
requested on line 8.
All others. See section 6103(e) if the taxpayer
has died, is insolvent, is a dissolved corporation,
or if a trustee, guardian, executor, receiver, or
administrator is acting for the taxpayer.
Note: If you are Heir at law, Next of kin, or
Beneficiary you must be able to establish a
material interest in the estate or trust.
Documentation. For entities other than
individuals, you must attach the authorization
document. For example, this could be the letter
from the principal officer authorizing an employee
of the corporation or the letters testamentary
authorizing an individual to act for an estate.
Signature by a representative. A representative
can sign Form 4506-C for a taxpayer only if the
taxpayer has specifically delegated this authority
to the representative on Form 2848, line 5. The
representative must attach Form 2848 showing
the delegation to sign Form 4506-C.
Privacy Act and Paperwork Reduction Act
Notice. We ask for the information on this form to
establish your right to gain access to the
requested tax information under the Internal
Revenue Code. We need this information to
properly identify the tax information and respond
to your request. You are not required to request
any transcript; if you do request a transcript,
sections 6103 and 6109 and their regulations
require you to provide this information, including
your SSN or EIN. If you do not provide this
information, we may not be able to process your
request. Providing false or fraudulent information
may subject you to penalties.
Routine uses of this information include giving it to
the Department of Justice for civil and criminal
litigation, and cities, states, the District of
Columbia, and U.S. commonwealths and
possessions for use in administering their tax
laws. We may also disclose this information to
other countries under a tax treaty, to federal and
state agencies to enforce federal nontax criminal
laws, or to federal law enforcement and
intelligence agencies to combat terrorism.
You are not required to provide the information
requested on a form that is subject to the
Paperwork Reduction Act unless the form displays
a valid OMB control number. Books or records
relating to a form or its instructions must be
retained as long as their contents may become
material in the administration of any Internal
Revenue law. Generally, tax returns and return
information are confidential, as required by section
The time needed to complete and file Form 4506-
C will vary depending on individual circumstances.
The estimated average time is:
Learning about the law or the form . . . 10 min.
Preparing the form . . . . . . . . . . . . . 12 min.
Copying, assembling, and sending
the form to the IRS . . . . . . . . . . . . . 20 min.
If you have comments concerning the accuracy of
these time estimates or suggestions for making
Form 4506-C simpler, we would be happy to hear
from you. You can write to:
Internal Revenue Service
Tax Forms and Publications Division
1111 Constitution Ave. NW, IR-6526
Washington, DC 20224
Do not send the form to this address. Instead, see
Where to file on this page.
RIHousing Help Center | 44 Washington Street Providence, RI 02903 | 401 457-1130
Homeowner/Counselor Agreement
The RIHousing Help Center and its counselors agree to provide the following services:
ment of a financial budget to determine homeowner’s income, expenses and affordability
Analysis of the mortgage default, including the amount and cause of default
Presentation and explanation of reasonable options available to the homeowner
Submit homeowner’s file to the lender for review for all retention and/or liquidation options available, based on
the homeowner’s eligibility and needs
Communicate with the mortgage servicer and/or investor and provide the homeowner with requests for any
additional/updated information as needed
Timely completion of action plan
Explanation of collection and foreclosure process
Identify and provide homeowner with information on additional resources that may be available
Confidentiality, honesty, respect and professionalism in all services
The HelpCenter cannot control the lender’s processing time or decision
The HelpCenter cannot and does not provide legal advice or representation. The informational services provided
by the HelpCenter are not a substitute for legal advice. The HelpCenter encourages homeowners to contact an
attorney if they feel they need legal advice or services
I/We ______ _____________________________ agree to the following terms of service:
will always provide honest and complete information to my/our counselor, whether verbally or in writing.
I/We will be on time for appointments and understand that if I/we are late for an appointment, the appointment may have
to be rescheduled
I/We will call within 24 hours of any future scheduled appointment(s) if I/we will be unable to attend an appointment.
I/We will follow up with our mortgage servicer and/or investor, on a bi-weekly basis, and provide the counselor with any
updates as well as provide the counselor with any correspondence or requests for any additional documentation.
I/We will provide all necessary documentation and follow-up information within 72 hours from the time requested.
I/We will contact the counselor about any changes in my/our situation immediately.
I/We will make an appointment with my/our counselor should any follow up face to face meeting be needed.
I/We understand that RIHousing will provide one counseling session per calendar year.
I/We understand that breaking this agreement may cause the HelpCenter to terminate its service assistance to me/us.
I/We understand that the HelpCenter is not providing legal advice or representation, and that the informational services
provided by the HelpCenter are not a substitute for legal advice. I/We understand that I/we should contact an attorney if
we wish to receive legal advice or services.
_________________ ______________
Homeowner Date
___________________ ______________
Homeowner Date
___________________ ______________
Homeowner Date
___________________ ______________
Counselor Date
___________________ ______________
Counselor Date
Page 12/13
Consent to the Use of Tax Return Information
I understand, acknowledge, and agree that Rhode Island Housing and Mortgage Finance Corporation and its
affiliates, agents, service providers, successors and assigns (collectively, “RIHousing”) can obtain, use, and share my
tax return information with the Loan Participants for the purpose of providing me with foreclosure prevention
counseling or as otherwise permitted by applicable law, including state and federal privacy and data security laws.
The Loan Participants include any actual or potential owners of my loan, or acquirers of any beneficial or other
interest in my loan, any mortgage insurer, guarantor, any servicers or service providers for these parties and any of
the aforementioned parties’ successors and assigns.
I understand that RIHousing’s HelpCenter is a housing counseling agency that is approved by the United States
Department of Housing and Urban Development (“HUD”). I acknowledge and agree that RIHousing can share
my tax return information with HUD for its program monitoring and compliance purposes.
Acknowledgment: By signing below I hereby acknowledge and agree that I have read and understood the
information that is set forth above.
Borrower Signature Date
Co-Borrower Signature Date
© 2019 The Mortgage Industry Standards Maintenance Organization. All rights reserved
Page 13/13
Rev. Jan-19
Financial companies choose how they share your personal information. Federal law gives
customers the right to limit some but not all sharing. Federal law also gives customers the right to
view personal records, and to correct a record that is inaccurate or incomplete. Federal law
requires us to tell you how we collect, share, and protect your personal information.
We provide this notice to customers at the time of application for RIHousing programs, products,
or services, and annually thereafter. From time to time, we may revise this notice to reflect
changes in the law or changes in our policies. Please read this notice carefully to understand what
we do.
The types of personal information we collect and share depend on the product or service you have
with us. This information can include:
Social Security Number
Account balance
Payment history
Credit history
Credit score
Date of birth
Medical information and blood lead level test results (for lead hazard reduction programs)
When you are no longer our customer, we continue to share your information as described in this
All financial companies need to share customers’ personal information to run their everyday
business. In the section below, we list the reasons financial companies can share their customers’
personal information; the reason RIHousing chooses to share; and whether you can limit this
Reasons we can share your personal information
Does RIHousing share?
Can you limit this
For our everyday business purposes such as to process
your transactions, maintain your account(s), respond to court
orders and legal investigations, or report to credit bureaus
For our marketing purposes to offer our products and
services to you
For joint marketing with other financial companies
For our affiliates’ everyday business purposes information
about your transactions and experiences
For our affiliates’ everyday business purposes information
about your creditworthiness
For nonaffiliates to market to you
*If N/A, RIHousing does not share your personal information so your ability to limit is not applicable.
Call (800) 854-1180 or (401) 457-1180
Who we are
Who is providing
this notice?
Rhode Island Housing and Mortgage Finance Corporation (“RIHousing”)
What we do
How does
RIHousing protect
my personal
To protect your personal information from unauthorized access and use, we use security measures
that comply with federal and state law and regulation. These measures include computer
safeguards and secured files and buildings.
How does
RIHousing collect
my personal
We collect your personal information, for example, when you:
Apply for financing
Give us your contact information
Give us your employment history
Give us your income information
Show us your driver’s license
We also collect your personal information from government agencies, public sources, and others,
such as credit bureaus, affiliates, or other companies.
Why can’t I limit all
Federal law gives you the right to limit only:
Sharing for affiliates’ everyday business purposes information about your
Affiliates from using your information to market to you
Sharing for nonaffiliates to market to you
Companies related by common ownership and control. They can be financial and nonfinancial
Our affiliates include Rhode Island Housing Development Corporation, Rhode Island Housing
Equity Corporation, Rhode Island Housing Equity Pool, L.P., and Rhode Island Housing Equity
Pool-I, L.P.
Companies not related by common ownership or control. They can be financial or nonfinancial
RIHousing does not share your personal information with nonaffiliates so they can
market to you.
Joint marketing
A formal agreement between nonaffiliated financial companies that together market financial
products or services to you.
RIHousing does not jointly market.
Other important information
Service providers with whom we share information for everyday business purposes may include coupon or statement
printers, billing services, payment processing companies, mail, print, and telephone service companies, insurers, property
inspection firms, government agencies, attorneys, laboratories, community action programs, auditors, quality control
vendors, consultants, or other service providers.
Provisions pertaining to protected medical information
In the context of carrying out certain residential lead hazard reduction programs, RIHousing may receive certain medical
information. A customer’s rights with respect to protected medical information include (a) the right to request
restrictions on certain uses and disclosures, subject to denial by RIHousing; (b) the right to receive confidential
communications of the information; (c) the right to inspect and copy the information; (d) the right to amend the
information; (e) the right to receive an accounting of disclosures of the information; and (f) the right to obtain a paper
copy of this notice upon request. A customer may complain to RIHousing if they believe their privacy rights have been
violated by writing a letter addressed to RIHousing, 44 Washington Street, Providence, RI 02903,
ATTN: Lead Program. A customer will not be retaliated against for filing a complaint.
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To: HelpCenter
Fax: 401-450-1373
Re: HelpCenter Financial Information Package