When we receive this form and all required documents, we’ll assign a team of dedicated specialists
to your loan who will call you within five business days to talk about your next steps.
For additional forms, please visit chase.com/MortgageAssistance
Si tiene alguna pregunta sobre asistencia hipotecaria, por favor llame al 1-877-496-3138.
ACKNOWLEDGMENT AND AGREEMENT
By signing this document, I/we certify that all the information is truthful.
I/We understand that knowingly submitting false information may constitute fraud.
Customer Signature______________________________________________________ Date ______/_____/________
Please read carefully and sign
REQUEST FOR MORTGAGE ASSISTANCE FORM
Loan Number: _
In making this request for consideration, I certify under penalty of
perjury that I understand and agree that:
1. The servicer of my mortgage loan may pull a current credit report for
all customers obligated on the Note for the loan.
2. If my liability for the mortgage debt was discharged in a Chapter 7
bankruptcy proceeding after I signed the mortgage documents, or if I
am entitled to the protections of any automatic stay in bankruptcy, the
servicer is providing information about the mortgage assistance
program at my request and for informational purposes, and not as an
attempt to impose personal liability for the mortgage debt.
3. If I am eligible for a Trial Period Plan, Repayment Plan or Forbear-
ance Plan, and I accept and agree to all the terms of such a plan, I
also agree that the terms of this Acknowledgment and Agreement are
incorporated into that plan.
4. If I'm eligible for an assistance option that requires an escrow
account to pay taxes and/or insurance and my mortgage loan doesn’t
have one, the servicer may establish one. If my loan previously had
an escrow account and the servicer agreed to remove this require-
ment, this agreement has been revoked.
5. All the information in this document is true, and the hardships listed in
Step 2 explain why I’m requesting mortgage assistance.
6. The servicer, owner, or guarantor of my mortgage or their agents may
investigate the accuracy of my statements and I may need to provide
7. The servicer may directly obtain copies of account statements,
including, but not limited to, checking and savings accounts,
certificates of deposit (even if held for an extended period of time),
mutual funds, money market funds, stocks or bonds, on accounts that
are held by the servicer, its subsidiaries and affiliates for the review of
my request for mortgage assistance.
8. If I have intentionally defaulted on my existing mortgage or engaged
in fraud, or if any of the information I’ve provided is false, I may be
ineligible for assistance under applicable investor/insurer programs or
guidelines. This includes ineligibility now and for any future benefits
and incentives that would otherwise have been available. I also
understand that the servicer may recover any benefits or incentives
I’ve previously received.
9. The property securing the mortgage I’m requesting assistance for
can be lived in and hasn’t been or isn’t at risk of being condemned.
10. The servicer will use the information I provide to determine my
eligibility for mortgage assistance, but isn’t obligated to offer me
assistance based solely on the statements in this or any other
document I send as part of this request.
11. The servicer will collect and record personal information, including
my name, address, phone number, Social Security number, credit
score, income, payment history and information about account
balances and activity. I understand and consent to the disclosure of
my personal information and the terms of any mortgage assistance
option I receive by the servicer to (a) any investor, insurer,
guarantor or servicer of my mortgage loan(s); (b) companies that
perform support services in conjunction with any other mortgage
relief program; and (c) any HUD-certified housing counselor.
12. The Servicer, Lender, and Other Loan Participants can obtain, use
and share tax return information for purposes of (i) providing an
offer; (ii) originating, maintaining, managing, monitoring, servicing,
selling, insuring, and securitizing a loan; (iii) marketing; or (iv) as
otherwise permitted by applicable laws, including state and federal
privacy and data security laws. References to “Servicer” and
“Lender” in the first sentence shall be deemed to include both
parties’ vendors, affiliates, agents, service providers, and any of
the aforementioned parties’ successors and assigns. The reference
to “Other Loan Participants” in the first sentence shall also include
any actual or potential owners of the loan, or acquirers of any
beneficial or other interest in the loan, any mortgage insurer,
guarantor, any servicers or service providers for these parties and
any of the aforementioned parties’ successors and assigns.
13. If I, or someone on my behalf, have submitted a Fair Debt
Collection Practices Act cease and desist notice to my Servicer, I
withdraw that notice and understand that the servicer must contact
me throughout the mortgage assistance process.
14. I consent to being contacted about this request for mortgage
assistance at any email address I have provided.
Additional Customer Signature_____________________________________________ Date ______/_____/________
Here’s how to send your documents
Here’s how you can send your information.
After you have submitted your documentation,
please call us at 1-877-496-3138 to let us know.
720 S. Colorado Blvd., STE 210
Glendale, CO 80246-1904
PO Box 469030
Glendale, CO 80246-9030
If you have questions about this document or the assistance process, please call Chase. If you have questions
about government programs that we cannot answer or you need further counseling, call the Homeowner’s
HOPE™ Hotline at 1-888-995-HOPE (4673). The hotline can answer questions about the program and offers free
HUD-certified counseling services in English and Spanish.
For a list of HUD-approved counseling agencies that can provide foreclosure prevention information, contact
the U.S. Department of Housing and Urban Development (HUD) at 1-800-569-4287 or hud.gov/counseling.
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