FORCLOSURE INTAKE FORM_Wealth Watchers

WEALTH WATCHERS INTAKE FORM

To better assist Wealth Watchers Inc in evaluating your situations, please fill out ALL the applicable fields below. A Wealth Watchers Inc staff members will be in contact with you within 24 hours of completing the online form.

If you have any questions, please do not hesitate to contact us at 904-265-4736 or at info@wealthwatchersfl.com.
How did you here about us?: *
Homeowner Name

First Name Last Name
Homeowner Date of birth: *

Month Day Year
Homeowner Race: *
Homeowner Gender: *
Homeowner Ethnicity Hispanic *

Yes No
Veteran: *

Yes No
Homeowner Employer Name *
Household Type: *
Highest Education Level: *
Total houseHold size: *
Household Income (all family members gross income): *
Address of property - do not use PO Box

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

County:
Preferred Contact: *
Home Phone

Area Code Phone Number
Mobile Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Email: *
Name of originating lender (on down), if known:
Original loan number:
Name of current servicer:
Total monthly payment (PITI) at intake:
Type of first loan product at intake: *
Is Loan
Interest only: *
FHA or VA fixed rate loan: *
FHA or VA ARM: *
Privately held: *
If Type of loan at intake is an ARM - has the interest rate already reset at least once? *
Primary reason for anticipated delinquency, delinquency, or default: *
Loan status at first contact: *

Street number: *
Monthly Expenses
Rent or Mortgage #1:
Rent or Mortgage #2:
Heating(gas or oil):
Electricity:
Water & sewer( /2mos)
Telephones (land lines)
Cell phone:
Homeowners Insurance (if seperate):
Property Taxes (if seperate):
Trash Service:
Home Maintenance and furnishings:
Other:
TRANSPORTATION
Gas:
Car payment #1:
Car payment #2:
Car Insurance:
Car Inspection:
Car Repairs & maintenance:
License Plates & registration fees:
Public transportation:
Parking & tolls:
Other:
FOOD
Groceries:
School Lunches:
Work related (lunches or snacks):
Other:
INSURANCE
Health (medical/dental if not payroll deducted)
Life:
Disability:
Other:
Medical
Doctor:
Dentist:
Prescriptions:
Other:
CHILDCARE
Childcare or babysitters:
Child support or alimony:
Other:
CLOTHING
Clothing:
Laundry and dry cleaning:
DONATIONS
Charity:
EDUCATION
Tuition and lessons:
Books, papers and supplies:
Newspapers and Magazines:
Other:
GIFTS
Birthdays:
Major holidays:
PERSONAL
Barber or beauty shop:
Toiletries:
Children's Allowances:
Tobacco products:
Beer, wine or liquor:
Other:
ENTERTAINMENT
Movies, sporting events, concerts:
Video rentals:
Internet service:
Cable/satellite TV:
Restaurants and take-out meals:
Gambling and lottery tickets:
Fitness or social clubs:
Vacation or trips:
Hobbies or crafts:
Other:
MISCELLANEOUS
Checking account fees:
Pet care and supplies:
Postage:
Other:
DEBT
Student loans:
Credit card #1 (monthly minimum):
Credit card #2 (monthly minimum):
Credit card #3 (monthly minimum):
Credit card #4 (monthly minimum):
Medical bills:
Personal loans(monthly minimum):
Dept management program:
Other:
OTHER
Other1:
Other2:
Total Monthly Income:
Total Monthly Expenses:
Difference:

Loan number:
I hereby authorize Wealth Watchers, Inc to obtain/release/exchange Information from my records in order to assist me in resolving a mortgage default.
This information will be released only to those institutions, companies and agencies that our organization believes can provide assistance in resolving a mortgage default. Examples of such entities include mortgage servicers, mortgage investors, public agencies and other nonprofit organizations. if necessary, information of file at another entity may also be released to us. This information release/exchange will be restricted to specific financial data, such as income, budget, debt and mortgage details provided by you.
I understand that the provision of services at this organization is not contingent upon my decision concerning the release/exchange of information.
The doctrine of informed consent has been explained to me, and i understand that contents to be released/exchanged, the need for the information, and that there are statutes of regulations protecting the confidentiality of authorized information.
I hereby acknowledge that this consent is voluntary and is valid until such request is fulfilled. I further acknowledge that I may revoke this consent at any time except to the extent that action based on this consent has been taken. I also acknowledge that a copy of this form is as valid as the original.
Click here for Authorization: *

I hereby authorize Wealth Watchers, Inc to obtain/release/exchange Information from my records in order to assist me in resolving a mortgage default.
Last four digits of SSN: *
Type Full Legal Name: *
Date:

Month Day Year
at
Hour Minutes AM/PM Option
Should be Empty: