Fillable FORECLOSURE MEDIATION FINANCIAL WORKSHEET (NJ Judiciary)

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FORECLOSURE MEDIATION FINANCIAL WORKSHEET (NJ Judiciary)

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FORECLOSURE MEDIATION FINANCIAL WORKSHEET
COUNTY
DOCKET NO: F
–
Plaintiff’s Name
v.
First Defendant’s Name
PERSONAL INFORMATION
Borrower’s Name Co-Borrower’s Name
Social Security Number Date of Birth (mm/dd/yyyy) Social Security Number Date of Birth (mm/dd/yyyy)
Married Civil Union/ Domestic Partner Married Civil Union/ Domestic Partner
Separated Unmarried (single, divorced, widowed) Separated Unmarried (single, divorced, widowed)
Dependents (Not listed by Co-Borrower) Dependents (Not listed by Borrower)
Present Address (Street, City, State, Zip) Present Address (Street, City, State, Zip)
EMPLOYMENT INFORMATION
Employer Self Employed Employer Self Employed
Position/Title Date of Employment Position/Title Date of Employment
Second Employer Second Employer
Position/Title Date of Employment Position/Title Date of Employment
ASSETS
Assets: Liquid Estimated Value Amt. Owed Net Value
Cash
Savings Accounts
Checking Accounts
Certificates of Deposits (CD’s)
Stocks/Bonds/Mutual Funds
All Retirement Assets (401(k)s, IRA’s, etc.)
Assets: Non-Liquid
Primary Home
Other Real Estate
Personal Property
Automobile 1
Automobile 2
Cash Value of Life Insurance
Other Assets (Limited Partnership, etc.)
Total
MONTHLY INCOME
Monthly Income: Borrower Co-Borrower Total
Gross Salary/Wages
Net Salary/Wages
Overtime Wages
Commissions
Bonuses
Social Security
Unemployment Income
Disability (short term or long term)
Rental Income
Child Support/Alimony
Pension
Other Contributory Income
Total Net (do not include Gross income)
Revised: 10/2012, CN 11269-English, (Foreclosure Mediation Financial Worksheet) page 1 of 2
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Revised 10/2012, CN 11269-English, (Foreclosure Mediation Financial Worksheet) page 2 of 2
EXPENSE AND LIABILITIES
Monthly Payments Balance Due # Mos. Delinquent
First Mortgage (plus real estate taxes)
Second Mortgage
Other Judgments
Homeowners’ Association Dues
Property Maintenance
Other Mortgages
Automobile Loan(s)
Automobile Insurance
Auto Expenses (gas, maintenance, etc.)
Student Loans (tuition, private school )
Child Support/Child Care
Dependent Care
Alimony
Medical Charges/Prescriptions
Utilities: Gas
Utilities: Electricity
Utilities: Water/Trash/Sewer
Home Telephone/Cell Phone
Cable TV/Internet
Groceries/Toiletries
Health Insurance (health, dental, etc., not
deducted from checks)
Leisure (hobbies, dining out, movies, etc.)
Contributions/Gifts (church donations, birthday
gifts, etc.)
Newspapers/Periodicals
Additional Expenses:
Credit Cards: (add separate sheet for additional
lines)
Credit Cards/Installment Loan
Credit Cards/Installment Loan
Credit Cards/Installment Loan
Credit Cards/Installment Loan
Credit Cards/Installment Loan
Total
I / We obtained a mortgage loan(s) secured by the above-described property.
I / We have described my/our present financial condition and reason for default and have attached required
documentation.
I / We consent to the release of this financial worksheet and attachments to the mediator and the plaintiff or
plaintiff’s servicing company by way of the plaintiff’s attorney.
By signing below, I / we certify the information provided is true and correct to the best of my / our knowledge.
Signature of Borrower Home Phone No. Cell Phone No. Date
Signature of Co-Borrower Home Phone No. Cell Phone No. Date
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FORECLOSURE MEDIATION FINANCIAL WORKSHEET (NJ Judiciary)

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Completed 1 April 2021

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