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Mortgage assistance application
For additional copies of this form, or to complete it digitally, visit Documents and Forms
on wellsfargo.com/homeassist.
Mortgage assistance application
1 of 5
About you
Borrower
First name
Last name
Last 4 digits of
Social Security number
Phone numbers
Home
Mobile
Work
Mailing address
Street (line 1)
Street (line 2)
City
State ZIP code
Email address
Co-borrower
First name
Last name
Last 4 digits of
Social Security number
Phone numbers
Home
Mobile
Work
Mailing address Check this box and skip to the next question if
the address is the same as the borrower’s
Street (line 1)
Street (line 2)
City
State ZIP code
Email address
Active duty military service
Is either borrower on active duty with the military (including
the National Guard and Reserves), the dependent of a
borrower on active duty, or the surviving spouse of a member
of the military who was on active duty at the time of death?
Yes No
QUICK TIP
Need assistance with
translation or other
language assistance?
HUD-approved
housing counseling
agencies may be able
to assist you. These
services are provided
without charge.
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About your property
Your property is a:
Primary residence Secondary residence
Investment property
What is your intent with your property?
Keep
Sell
Undecided
Transfer ownership of the property to Wells Fargo.
Who lives in your property?
You (borrower or co-borrower)
Resident other than the borrower
and not a renter
It is vacant
Renter
Has the property been a
rental property for more
than a total of 18 months?
Yes
No
What is the address of your property that
you’re seeking assistance for?
Check this box if the address is the same as the borrowers address listed
on the rst page.
Street (line 1)
Street (line 2)
City State
ZIP code
Do you pay condominium, co-op, homeowners association fees
or other fees, associated with your housing?
Yes
No (skip to the next question)
If yes: How much do you pay per month?
$
Are your fees current?
Yes No
Who pays your homeowners insurance?
I pay it Paid by condominium, co-op, or homeowners association
Is your property currently listed for sale?
Yes
No
If yes:
Who is selling your home?
An agency/agent
I am selling the home myself
(for sale by owner)
About your employment
Are you (the borrower) employed?
Yes
If yes: When did you begin your primary job?
(MM/DD/YYYY)
When did you begin your secondary job?
(if applicable) (MM/DD/YYYY)
No
If no:
When did you become unemployed?
(if applicable) (MM/DD/YYYY)
Is the co-borrower employed?
Yes
If yes: When did you begin your primary job?
(MM/DD/YYYY)
When did you begin your secondary job?
(if applicable) (MM/DD/YYYY)
No
If no:
When did you become unemployed?
(if applicable) (MM/DD/YYYY)
Mortgage assistance application
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Financial worksheet
You must disclose all income that you receive. Include your and the co-borrowers combined income.
Individuals at your property address who aren’t on the loan as co-borrowers are considered to be
non-borrowers. Non-borrowers can contribute income to the review of your loan modication;
they should ll out the Non-Borrower Financial Contribution Form.
What is your monthly household income?
Before-tax (gross) wages, salaries,
and overtime pay, commissions,
tips and bonuses
$
Self-employment income
$
Unemployment benet income
$
Taxable Social Security benets
$
Pension, disability, death benets,
adoption assistance, housing
allowance, and public assistance
$
NonTaxable Social Security benets
and Social Security Disability Insurance
$
QUICK TIP
If you have rental income from more than
one property, you’ll need to print and ll out
an additional Schedule of Real Estate Owned
form and include it with your application.
You can nd it under Documents and
Forms on wellsfargo.com/homeassist.
Example
$
2,500.00
Rental income (rents received
minus expenses other than
mortgage expense)
$
Investment or insurance income
$
QUICK TIP
You’re not required to reveal your alimony,
child support, or separate maintenance
income if you don’t want us to consider it
for the application.
Other sources of income
not listed above
$
What are your household assets?
Checking account(s) and
$
cash on hand
$
Savings/money market funds/
$
Certicates of Deposit (CDs)
$
Stocks and bonds (only include
$
non-retirement accounts)
$
QUICK TIP
Don’t include retirement plans when
calculating your assets (401(k) plans,
pension funds, IRAs, Keogh plans, etc.).
Other
$
Mortgage assistance application
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Hardship adavit
Your answers to the following questions will help us better assess your nancial
hardships and determine what relief options are right for you.
The hardship causing mortgage payment
challenges began on approximately
(MM/DD/YYYY)
We believe that the hardship has lasted or will last:
1-6 months
7-12 months
12+ months or permanently
This hardship was resolved as of
Check all of the nancial diculties that are relevant to you. We have diculty making our monthly payment because of:
Unemployment
No hardship documentation required
Reduced household income due to circumstances outside our
control. For example:
Reduced pay or hours
Elimination of overtime
No hardship documentation required
Increased housing expenses due to circumstances outside our
control. For example:
• Uninsured losses
Increased property taxes
No hardship documentation required
Natural or man-made disaster impacting the property
or place of our employment.
No hardship documentation required
Long-term or permanent disability, or serious illness, aecting us
or a dependent family member.
Please provide:
Written statement or other documentation that veries
disability or illness
Detailed medical information is not required, and information
from a medical provider is not required.
Divorce or legal separation
Please provide:
Final divorce decree or nal separation agreement
Or recorded quitclaim deed
Separation of borrowers unrelated by marriage, civil union, or
similar domestic partnership under applicable law.
Please provide:
Recorded quitclaim deed
Or legally binding agreement that shows that the
nonoccupying borrower or co-borrower has relinquished
all rights to the property
Death of the borrower or death of either the primary or secondary
wage earner in the household
Please provide:
• Death certicate
Or obituary or newspaper article reporting the death
Distant employment transfer or relocation
For active duty service members, please provide
Permanent Change of Station (PCS) orders
or letter showing transfer
For employment transfers/new employment, please provide
Copy of signed oer letter or notice from employer showing
transfer to a new employment location or written explanation
if employer documentation is not available
In addition to the above, documentation that reects the
amount of any relocation assistance provided (not required if
you have PCS orders)
Other hardship
Provide your description of the hardship and provide
related documentation.
QUICK TIP
If you need more space, you can continue on a separate page and
submit it by mail.
Mortgage assistance application
4 of 5
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Acknowledgment and agreement
I/We understand that I/we will be considered for all mortgage assistance options
available to me/us. I/We certify the following:
1. All information in this adavit is true and accurate and the
events identied are the reason that I/we need to request a
modication of the terms of my/our mortgage, short sale, or
deed in lieu of foreclosure.
2. I/We consent to the servicer or authorized third party obtaining
a current credit report for the borrower and co-borrower. An
authorized third party may include, but is not limited to, a
housing counseling agency, Housing Finance Agency (HFA)
or other similar entity that is assisting me/us in obtaining a
foreclosure prevention alternative.
3. I/We understand that if I/we have intentionally defaulted on
my/our existing mortgage, engaged in fraud, or misrepresented
any facts in connection with this document, the Servicer may
cancel any Agreement and may pursue foreclosure on my/our
home and/or pursue any available legal remedies.
4. I/We are willing to provide all requested documents and to
respond to all Servicer questions in a timely manner.
5. I/We understand that the Servicer will use the information in this
document to evaluate my/our eligibility for a loan modication,
short sale, or deed in lieu of foreclosure, but the Servicer is
not obligated to oer me/us assistance based solely on the
statements in this document.
6. If I/we are eligible for a modication, repayment plan, or
forbearance plan, and I/we accept and agree to all terms of such
plan, I/we also agree that the terms of this acknowledgment and
agreement are incorporated into such plan by reference as if set
forth in such plan in full.
7. My/Our rst timely payment following my/our Servicers
determination and notication of my/our eligibility or
prequalication for a modication, repayment plan, or
forbearance plan (when applicable) will serve as acceptance of
the terms set forth in the notice sent to me that sets forth the
terms and conditions of the modication, repayment plan, or
forbearance plan.
8. I/We agree that when the Servicer accepts and posts a payment
during the term of any repayment plan, modication, or
forbearance plan, it will be without prejudice to, and will not
be deemed a waiver of, the acceleration of my/our loan or
foreclosure action and related activities and shall not constitute
a cure of my/our default under my/our loan unless such
payments are sucient to completely cure my/our entire default
under my/our loan.
9. I/We agree that any prior waiver of an escrow account
requirement for this loan may be revoked and an escrow
account may be established, upon execution of this agreement,
and in accordance with investor guidelines.
10. I/We understand that the Servicer will collect and record
personal information, including, but not limited to, my/our
names, address, telephone number, Social Security numbers,
credit score, income, payment history, and information about
account balances and activity. I/We understand and consent to
the disclosure of my/our personal information to (a) any investor,
insurer, guarantor, or Servicer that owns, insures, guarantees,
or services my/our rst lien or subordinate lien (if applicable)
mortgage loan(s); (b)companies and/or individuals that perform
support services in conjunction with home preservation
mortgage assistance eorts; (c) auditors, including but not
limited to independent auditors, regulators, and agencies; and
(d) any HUD-certied housing counselor.
11. I/We understand that the Servicer may investigate the accuracy
of my/our statements, including contacting my/our employers
for verication of employment and/or salary information, may
require me/us to provide supporting documentation, and that
knowingly submitting false information may violate federal law
and may result in foreclosure.
12. I/We consent to being contacted concerning this application for
mortgage assistance at any telephone number, including mobile
telephone number, or email address I/We have provided to the
lender, servicer, or authorized third party.
Mortgage assistance application
5 of 5
Borrower signature(s)
The undersigned certies under penalty of perjury that all
statements in this document are true and correct:
Borrower’s signature
Date (MM/DD/YYYY)
Co-borrower’s signature
Date (MM/DD/YYYY)
PQ October 2018 MAA © 2018 Wells Fargo Bank, N.A. All rights reserved. NLMSR ID 399801
ECG-3412302
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