Foreclosure Prevention Registration Form
Today's Date:
5/17/2008
First Name:
Last Name:
Address:
City:
County:
State:
Zipcode:
Home Phone:
Cell Phone:
Work Phone:
When is the best time to contact you?
a.m.
p.m.
Please indicate the number of months you are currently behind on your mortgage payment?
1 month
2 months
3+ months
Please check the items below that best describe your current foreclosure situation:
Predatory lending
Loss of job
Loss of income
Budgeting/financial mismanagement
Divorce
Death
Other
If "Other", please describe:
Are there minor children (18 yrs or younger) in your household?
Yes
No
Would you like more information regarding AMHA or other housing options?
Yes
No
Items in BOLD are required.
© 2008 The Akron Metropolitan Housing Authority
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