Free Foreclosure Mediation Financial Worksheet - New Jersey

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FORECLOSURE MEDIATION FINANCIAL WORKSHEET

DOCKET NO: F
Plaintiff's Name Borrower's Name Social Security Number Date of Birth (mm/dd/yyyy)

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v. PERSONAL INFORMATION
Co-Borrower's Name

First Defendant's Name

Social Security Number

Date of Birth (mm/dd/yyyy)

Married Civil Union/ Domestic Partner Separated Unmarried (single, divorced, widowed) Dependents (Not listed by Co-Borrower) Present Address (Street, City, State, Zip)

Married Civil Union/ Domestic Partner Separated Unmarried (single, divorced, widowed) Dependents (Not listed by Borrower) Present Address (Street, City, State, Zip)

EMPLOYMENT INFORMATION
Employer Position/Title Second Employer Position/Title Date of Employment Borrower Self Employed Date of Employment Employer Position/Title Second Employer Position/Title Co-Borrower Date of Employment Total Self Employed Date of Employment

Gross Salary/Wages Net Salary/Wages Unemployment Income Child Support/Alimony Disability Income Rental Income Other Income Total (do not include Gross income)

0.00

0.00
Balance Due

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

EXPENSE AND LIABILITIES
First Mortgage Second Mortgage Other Liens/Rents Homeowners' Association Dues Hazard Insurance Real Estate Taxes Child Care Health Insurance Medical Charges Credit Card/Installment Loan Credit Card/Installment Loan Credit Card/Installment Loan Automobile Loan 1 Automobile Loan 2 Auto/Gasoline/Insurance Food/Spending Money Water/Sewer/Utilities Phone/Cell Phone Other Total
Monthly Payments

0.00

$0.00
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Effective: 11/2008, CN 11269-English, (Foreclosure Mediation Financial Worksheet)

ASSETS
Personal Residence Real Property Personal Property Automobile 1 Automobile 2 Checking Accounts Saving Accounts IRA/401K/Keogh Accounts Stock/Bonds/CDs Cash Value of Life Insurance Other Total Reason for Delinquency/Inability to Satisfy Mortgage Obligation: Reduction in income Poor budget management skills Loss of Income Other: Medical issues Increase in expenses Divorce/separation Death of family member Business venture failed Increase in loan payment
Estimated Value

$0.00

Further Explanation:

I / We obtained a mortgage loan(s) secured by the above-described property. I / We have described my/our present financial condition and reason for default and have attached required documentation. I / We consent to the release of this financial worksheet and attachments to the mediator and the plaintiff or plaintiff's servicing company by way of the plaintiff's attorney. By signing below, I / we certify the information provided is true and correct to the best of my / our knowledge.

Signature of Borrower

SSN

Date

Signature of Co-Borrower

SSN

Date

Please attach the following: Last federal tax return filed Proof of income (e.g. one or two current pay stubs) Past two (2) bank statements If self-employed, attach a copy of the past six month's profit and loss statement

This is an attempt to collect a debt and any information obtained will be used for that purpose.

Effective: 11/2008, CN 11269-English, (Foreclosure Mediation Financial Worksheet)

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