Residential Foreclosure Mediation Questionnaire

Circuit Court for 13th Judicial Circuit, LaSalle County Andrew F. Skoog, Circuit Court Clerk Residential Foreclosure Mediation Questionnaire You have been named as a party in a foreclosure case. This case may result in the loss of your home. Court sponsored mediation may be available in your case. Mediation is a free, confidential, and voluntary process through which you and the lender that is seeking foreclosure of your home may discuss ways to resolve this case including reinstatement of the loan and renegotiation of the loan terms. THIS IS NOT AN EVICTION. Una version en Espanol de esta forma, Initial Questionnaire Form, es disponible en el siguiente sitio web, www.lasallecounty.com, o en el departmamento de Circuit Clerk, LaSalle County Courthouse, (119 W. Madison Street, Ottawa, IL). Usted ha sido nombrado/a como parte en una ejecucion hipotecaria. Esto puede resultar en la perdida de propiedad. ESTO NO ES UN DESALOJO. Please fill in the information on this form and bring it with you to the Foreclosure Mediation Prescreening meeting. The date and location of that meeting is contained in the Notice to Homeowners you received with your summons. The information provided will be used by the Court Mediator to make an initial determination if this case is suitable for mediation. This information will not be shared with anyone, unless you agree and then only with a representative of your mortgage lender. Name: ___________________________________ Case Number: _____________________________ Address: _____________________________ _______________________ Daytime Phone: 1. What is the total amount of your scheduled monthly payment to you lender? 2. If you property tax and property insurance are not included to the payment to your lender, what is the amount of your monthly property taxes and property insurance? 3. How many payments have you missed? 4. What are your monthly expenses not including the above monthly payments to your lender and any payments for property taxes and insurance? 253535 1 American LegalNet, Inc. www.FormsWorkFlow.com 5. What is your monthly income? Gross (before withholding) _______________________; Net Take-Home pay (after all deductions) _____________________________________. 6. Do you have any money saved? (CIRCLE ONE) YES NO 7. Do you have any other real property other than the property that is being foreclosed? (CIRCLE ONE) YES NO 8. Check all items that have caused you to miss payments: Injury or Illness Loss of Employment Adjustable Interest Rate/Balloon Payment My expenses Exceed my income If so, what is the difference between the value of the property and any mortgage or lien on the property? _________________________ How much?______________ Other:____________________________________________________ 9. If you marked Injury or Illness in question 8, are you now well? Yes No 10. If you marked "Loss of Employment" in Question 8, have you found a new job? Yes No 11. Do you desire to keep the property that is the subject of this case? Yes No 253535 2 American LegalNet, Inc. www.FormsWorkFlow.com 12. If your answer to question 11 was No, would you consider the following? (Check all that apply.) Deeding Property to Lender Selling Property to third party Consenting to Foreclosure (No deficiency judgment) 13. Is there are information that would be helpful in determining whether your case would be suitable for mediation? If so, please describe: _____________________________ Property Owner's Signature _____________________________ Co-Property Owner's Signature I consent to disclosure information to lender representative __________________ __________________ Initials 253535 3 American LegalNet, Inc. www.FormsWorkFlow.com