"I want to thank you for helping my family stop the foreclosure on our home. You did everything you said you would, like you said you would and we cannot thank you enough!" - B.H. and D.H. - New York

UCMA Personal Profile

Name: United Capital Mortgage Assistance
Address: 402 Vine Street, Woodstock, IL, 60098, US
Telephone: 800-474-1407

7115 Virginia Road, Suite 107
Crystal Lake, Illinois 60014
1.815.883.0226

This is not a contract and all information provided
will be held in strict confidence.

Address Where You Live
How did you hear about us? (If referred by someone, please type the name of the person who referred you)
	Mr. Mrs. Ms. Miss
Your Name
Co-Applicant's Name
Home Telephone Number
Cell Telephone Number
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 E-Mail Address
Street Address
City, State and Zip
Your Current Employment
Employer's Name
Street Address
City, State and Zip
Job Title / Duties
Do you have any Real Estate or Mortgage background or experience?	Yes No
Other than possibly above, have you ever been self-employed?	Yes No
Have you ever owned, operated or worked with any other firm that provides products or services similar to UCMA?	Yes No
Please tell us a little more about yourself and why you would like to offer Loss Mitigation services.
I hereby state that the information on this form is true and accurate to the best of my ability Yes No
Signature (Your Name)