Borrower Authorization of Third Party Step 1 of 3 33% Mortgage Servicer Name* Customer Service/Loss Mitigation Phone Number* Borrower Full Name* Co-Borrower Full Name* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mortgage Loan Account Number* Third Party InformationThis section is for your reference. Please do not make any changes to any of the information. It will result in longer processing times.Name of Entity, Agency, Firm Phone Number Name(s) of Authorized Person(s) Mailing Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Office Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Website Tax ID # State License #Issuing State For non-profit agencies only* HUD Approved Counseling Agency? Yes No Approval Valid Until (date) MM slash DD slash YYYY HUD HCS # Attach National Foreclosure Mitigation Counseling form if needed For attorneys only* Do you represent the above named Borrower for a workout arrangement with the named Servicer? Yes No Firm Name Individual Attorney name(s) ** Attorney who represents Borrower must sign below All states where licensed Third Party AcknowledgementThe undersigned, on behalf of the Third Party, represents that: (i) it is in compliance with Regulation O (Mortgage Assistance Relief Services), if applicable, and all other applicable laws and regulations; and (ii) the Third Party information provided above is true and correct. The undersigned acknowledges that a misrepresentation or omission of fact made in connection with a government program such a Making Home Affordable may result in civil /criminal prosecution. Signature of Third Party Date MM slash DD slash YYYY Print Name(s) Title Borrower Authorization (please initial all items)Third Party you are Authorizing (from first page) I (Borrowers listed below) authorize the above named Third Party to discuss, assist with, or, if applicable, negotiate a workout arrangement on my mortgage(s) with the above named Mortgage Servicer (its affiliates, agents, employees, and successors). A workout arrangement could include a modification or other relief. I authorize my Mortgage Servicer, and Third Party and Treasury (and its agents) to share with each other public and non-public information about my finances and my mortgage for the purpose of assisting me in obtaining a workout arrangement, including but not limited to: (i) my mortgage payment history, terms of my mortgage; and (ii) my social security number, credit score, income, debts and other information related to obtaining and servicing my mortgage. I understand that my Mortgage Servicer may contact me directly except in limited situations, such as when I am represented by an attorney, and the Servicer and I must agree to any workout arrangement. I may still contact my Mortgage Servicer at any time. I understand that this Third Party Authorization Form may not be accepted by my Mortgage Servicer and my Mortgage Servicer will notify me in writing if it is not accepted. Mortgage Loan Servicers have procedures designed to detect fraud or improper activity and must follow privacy laws to protect borrower information. This Authorization expires one year from the date signed unless Borrower cancels it earlier by writing to the Servicer or by completing an Authorization of a different Third Party. Initials*Please initial in acknowledgment of statements outlined above. Do not sign this form until the form is fully completed. Keep a copy of this form. Beware of scams! Federal and State government agencies have prosecuted hundreds of companies and lawyers who illegally charge up-front fees. Report scams at HOPE Hotline: 888-995-HOPE (4673) Signature of Borrower*Printed Name* Date* MM slash DD slash YYYY Social Security Number* Phone*Email* Signature of Co-BorrowerPrinted Name Date MM slash DD slash YYYY Social Security Number PhoneEmail This form should be transmitted to the Mortgage Servicer as soon as possible and no later than 90 days after the date signed.
