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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 cards, 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 $