Citi


Customer Hardship Assistance Package

Instructions:
Please complete all required fields. To expedite the process, please also complete as many of the optional fields as possible.

CitiMortgage Hardship Assistance Package
 
* Required Fields
* *
 -X
Please enter all digits before the dash.
Example: if your account number is: 0000567890-1, input 567890.
Borrower Information Co-Borrower Information
* *  
 
*  
  Please Note: For any international phone numbers, please enter in the freeform box at the bottom of this form.
*  
 -   -   -   - 
   
 -   -   -   - 
   
 -   -   -   - 
   
Property Address Mailing Address (If different than Property Address)
*  
*  
*   State:
 
*  
 -    -  

Employment Information
 

   
 
   
 -   -   -   - 
   
  Years on Job:   Years on Job:
     
 
Please enter the second job employer information below, if applicable:
 
 
   
   
 -   -   -   - 
   
  Years on Job:   Years on Job:
   
 
If employed at current job for less than 5 years, please enter the previous employer information below:
 
 
   
 
   
 -   -   -   - 
   
  Years on Job:   Years on Job:
   

Property Information
 

* *
 Yes   No  Yes   No
          
mm-dd-yyyy mm-dd-yyyy    $.00
          
$.00 $.00    
         
       
         
 -   -         

Monthly Income Information
 
Please round amounts to the nearest dollar.
 
  Borrower Salary Information Co-Borrower Salary Information
*      
$ .00 $ .00    
*     Total
$ .00 $ .00   $0.00
  1. Additional Income Type Additional Income Type  
$ .00 $ .00 $0.00
  2.Additional Income Type Additional Income Type  
$ .00 $ .00 $0.00
 
  Total Net Personal Income Total Net Personal Income  
  $0.00   $0.00   $0.00

Monthly Expenses
 
Please round amounts to the nearest dollar.

Description (Monthly) Monthly Payment Balance Due Number of Months Delinquent
1. Primary Home Mortgage
(If Escrowed, include Taxes and Insurance)
$ .00 $ .00
2. Taxes on Primary Home
(If not included in #1)
$ .00 $ .00
3. Insurance on Primary Home
(If not included in #1)
$ .00 $ .00
4. Rent Payment
(if owner not occupying subject property)
$ .00 $ .00
5. Maintenance/Homeowners Association Fees $ .00 $ .00
6. Other Mortgages
$ .00 $ .00
7. Automobile Loans $ .00 $ .00
8. Other Loans $ .00 $ .00
9. Credit Cards (minimum payment) $ .00 $ .00
10. Alimony / Child Support $ .00 $ .00
11. Child/Dependent Care $ .00 $ .00
12. Utilities
(water, electricity, gas, cable, etc.)
$ .00 $ .00
13. Telephone
(land line and cell phone)
$ .00 $ .00
14. Insurance
(automobile, health, life)
$ .00 $ .00
15. Medical Expenses
(uninsured)
$ .00 $ .00
16.Car expenses
(gas, maintenance, parking)
$ .00 $ .00
17. Groceries and Toiletries $ .00 $ .00
18. Other Monthly Expense
(Explain)
$ .00 $ .00
19. Other Monthly Expense
(Explain)
$ .00 $ .00
20. Other Monthly Expense
(Explain)
$ .00 $ .00
 
Total Personal Expenses (lines 1 through 20): $0.00 $0.00  
Total Net Disposable Income $0.00
(Total Net Personal Income - Total Personal Expenses = Total Net Disposable Income)
 

General Questions
 
*  Yes   No
  If yes, please answer the following 3 questions:
  How long at this residence?   years months
  How many people in the household?  
  How many dependents under the age of 18?  
 
*
Example: Second Mortgage, Home Equity Loan, Judgments, or Liens.
 Yes   No
 
If yes, please itemize debts: Amount
Obligation/Debt #1: $ .00
Obligation/Debt #2: $ .00
Obligation/Debt #3: $ .00
   
 
* $ .00
*
$ .00
*    
 
  Only letters, numbers, spaces and periods are allowed in the text box below.
   
  0 characters entered. 2000 characters remaining
 
     
 
  Only letters, numbers, spaces and periods are allowed in the text box below.
   
  0 characters entered. 2000 characters remaining
 

Print

I certify that the financial information stated above is true; and is an accurate account of my financial condition. I grant CitiMortgage, Inc. the authority to confirm the information I have disclosed in this financial statement and to verify that it is accurate.