Section A: Mortgage Lates
Within the last 24 months have you had any late payments on your mortgage?
No
Yes
If yes, continue, otherwise skip to section B.
Number of Mortgage
Lates
Within the last 12 months
Between 13 and 24 months ago
30-59 days late
?? 0
1 2
3 4 5
6 7
8 9 10
11 12
30-59 days late
?? 0
1 2
3 4 5
6 7
8 9 10
11 12
60-89 days late
?? 0
1 2
3 4 5
6 7
8 9 10
11 12
60-89 days late
?? 0
1 2
3 4 5
6 7
8 9 10
11 12
90+ days late
?? 0
1 2
3 4 5
6 7
8 9 10
11 12
90+ days late
?? 0
1 2
3 4 5
6 7
8 9 10
11 12
Are you currently late on your
mortgages?
?? No
Yes
Section B: Consumer Loan Lates
Have you had any late payments on your credit cards, auto loans, student loans or any other consumer debts?
No
Yes
If yes continue, otherwise skip to section C.
Number of Consumer
Lates
Within the last 12 months
Between 13 and 24 months ago
30-59 days late
?? 1
2 3
4 5 6
7 8
9 10 11 12
30-59 days late
?? 1
2 3
4 5 6
7 8
9 10 11 12
60-89 days late
?? 1
2 3
4 5 6
7 8
9 10 11 12
60-89 days late
?? 1
2 3
4 5 6
7 8
9 10 11 12
90+ days late
?? 1
2 3
4 5 6
7 8
9 10 11 12
90+ days late
?? 1
2 3
4 5 6
7 8
9 10 11 12
Are you currently late on your
consumer loan payments?
No
Yes
Section C: Collections, Charge offs, Judgements, Tax Liens
Do you have any collections, charge offs, judgements or tax liens?
NO
Yes, within the last month
Yes, within the last 3 months
Yes, within the last 6 months Yes, within the last 1 year Yes, within
the last 2 years Yes, within the last 3 years
Yes, more than 4 years ago
Section D: Bankruptcies
Have you been bankrupt during the last 7 years?
No
bankruptcies over the last 7 years Currently in
bankruptcy Bankruptcy discharged less than 3
months ago Bankruptcy discharged less than 6
months ago Bankruptcy discharged over 1 year ago
Bankruptcy discharged over 2 years ago
Bankruptcy discharged over 3 years ago
Bankruptcy discharged over 4 years ago
Bankruptcy discharged over 5 years ago
Bankruptcy discharged over 6 years ago
Bankruptcy discharged over 7 years ago
Bankruptcy discharged over more than 7 years ago
Section E: Foreclosures
Have you had any foreclosures during the last 7 years?
No foreclosures Currently in foreclosure
Had a foreclosure less than 3 months ago
Had a foreclosure less than 6 months ago
Had a foreclosure less 1 year ago Had a foreclosure less 2 years ago Had a
foreclosure less 3 years ago Had a foreclosure less
4 years ago Had a foreclosure less 5 years ago
Had a foreclosure less 6 years ago
Had a foreclosure less 7 years ago Had a foreclosure more than 7 years ago
Section F: Payment load
Do you have a lot of consumer debts, such as credit cars, auto loans, student loans, etc.?
I pay my credit cards in full every month I have some debts,
but I am managing ok My debts are excessive, I need help I have no credit cards, car loans or student
loans
Section G: Equity in your property
The value of my house is $
The total amount of loans on my house are $