"Thank you for your tireless work to save our home. Today we signed our Loan Modification and saved our home because of your hard work. I cannot thank you enough." - F.L.H. - Louisiana

Apply Online - Qualify for a Loan Modification

For Faster Results - Please Complete Our
No Obligation Financial Analysis

Please complete and submit the following form, one of our expert staff will be calling you from our toll-free number, 1.800.474.1407, with your FREE no obligation financial analysis in hand. We will answer any and all questions you may have, go through the information you supply us with, help you understand the foreclosure process in your state and explain exactly what programs are available to help you keep your home.

All information entered is encrypted, forwarded exclusively to UCMA and is kept personal and confidential. Should you prefer to speak to one of our staff members, please call us toll-free at 1.800.474.1407, thank you.

Should you prefer not to complete this form, Please Click Here to fill-out our short contact form, thank you.

How did you hear about us? (If referred by someone, please type the name of the person who referred you.) SSL
Salutation Mr.  Mrs.  Ms.  Miss 
Your Name
Your Home Telephone Number
Your Cell Telephone Number
Your Work Telephone Number
How do you prefer to be contacted? Home Telephone  Cell Phone
Work Telephone
What is the best time of day to contact you?
At Home
By Cell Phone
At Work
Your Email Address
Are you currently late with any of your mortgage payments? Yes  No
If yes - how many payments have you missed including this month? 1st Mortgage  2nd Mortgage
Can you currently afford to pay all of your monthly bills and your mortgage payment(s)? Yes  No
Do you have a commitment to remain in your home? Yes  No
How long have you owned your home?
When did you last refinance your loan?
Please, briefly describe what event or events have occurred to cause you to fall behind on your mortgage payments.
Have you received any letters from your Mortgage Lender's attorneys or received any court documents? Yes  No
Is there a Foreclosure Sale date set for the sale of your home? Yes  No
If yes - what is the date of the Foreclosure Sale? Month Day Year(MM-DD-YYYY)
Homeowner's Information:
Your Name
Is Your Name on the Mortgage? Yes  No
Your Spouse's / Other's Name
Is Your Spouse's / Other's Name on the Mortgage? Yes  No
How many Adults in your household?     How many Children in your household?
Address Where You Live:
Street Address
City, State and Zip Code
Address of property behind on payments:
(if same as above, please leave blank)
Street Address
City, State and Zip Code
Mortgage Lender's Name(s):
1st Mortgage Lender's Name
2nd Mortgage Lender's Name (if any)
Have you ever had a Loan Modification in the past? Yes  No
Has it been greater than 2 years since the last Loan Modification? Yes  No
Monthly Mortgage / Other Loan Payments:
1st Mortgage Payment $
What type of loan is your 1st Mortgage? FHA   VA   Conventional   Unknown
Is your 1st Mortgage a Fixed Rate or Adjustable Rate Mortgage? Fixed Rate Adjustable Rate Mortgage
What is your current interest rate? % Unknown
Are Real Estate Taxes and Homeowner's Insurance included with your Mortgage Payment? Yes   No
2nd Mortgage Payment (if any) $
1st Automobile Loan Payment $
2nd Automobile Loan Payment $
Personal Loans / Student Loans and any Finance Company Payments (monthly payments combined) $
Monthly Credit Card Payments (combined) $
Other Monthly Loan Payments $
Other Monthly Payments:
(please use the average monthly payment for each payment, thank you)
Monthly Food Expenses $
Monthly Electric and Heating Bill Expenses (combined) $
Monthly Water / Sewer / Garbage Expenses $
Monthly Telephone Expense $
Monthly Cell Phone Expense $
Monthly Cable TV / Satellite Expense $
Monthly Homeowner's Association or Condo Fees $
Monthly Gasoline Expense $
Monthly Public Transportation / Car Pooling and Parking Expenses $
Monthly Automobile Insurance Expense $
Monthly Clothing / Dry Cleaning Expense $
Monthly Home Security / Home Alarm System $
Monthly Day Care Expenses $
Monthly Child Support Expenses $
If you have Child Support Expenses -
Is your Child Support Payroll Deducted? Yes   No
Monthly Clubs / Sports / Gym and Hobby Expenses $
Monthly Entertainment / Spending Money $
Monthly Church Contributions $
Monthly Prescription / Medical Expenses $
Other Monthly Expenses $
Other Monthly Expenses $
Monthly Household Income:
Your Monthly Income (take home pay / net income) $
Your Spouses or Other's Monthly Income (take home pay / net income) $
Other Monthly Income $
Other Monthly Income $
Bankruptcy Information:
Have You Filed Bankruptcy Since You Bought Your Home? Yes   No
If Yes - Was the Bankruptcy Completed? Yes   No
Amount Behind / Money Saved:
Approximately how much money will it take to bring your mortgage payments current?
How much money have you been able to save to give to your mortgage lender?
I/WE hereby authorize the release of this information to United Capital Mortgage Assistance and its foreclosure prevention associates only, and therefore do not authorize the release of this information to any other person, person(s), corporation, entity or otherwise.
Your Name
Call me/us right away. Yes   No

Please review our Confidentiality Policy