New York State Banking Department
Loan Subject to Pre-Foreclosure Notice
1. Filing Information
(a) Is this loan on a Primary Residence? Yes No
If you responded NO, please do not complete the remainder of this form
(b) Date of Mailing of Pre-Foreclosure Notice Month Day Year
2. Lien Holder Information
(If note is held by MERS, please provide name and information for current beneficial owner, or the trustee in the case of securitization).
Name
Address Street State Zip
Telephone Number
E-mail Address
3. Servicer Information
Name
Address Street State Zip
Telephone Number
E-mail Address
4. Agent of Lien Holder for purpose of resolution (if different from servicer only)
Name
Address Street City State Zip
Telephone Number
E-mail Address
5. Property Information
Address Street City State Zip
Type of Property 1 to 4 family Home CoOp Condo Other (please specify)
6. Borrower Information
Name Last: First:
Address Street City State Zip
Telephone Number Daytime: Alternative Number:
Has the borrower declared bankruptcy? Yes No
Has the borrower contacted you through a loan counselor or other representative? Yes No
7. Loan Details
(a) Original Lender
(b) Date of Loan Month Day Year
(c) Type of Loan 1st Lien Junior Lien Refinance (no cash out) Refinance (cash out) Home Equity
Other (please specify)___________________________________________
(d) Loan Detail Fixed Rate Adjustable Rate Payment Option Adjustable Rate Interest Only
If Adjustable Rate loan Frequency of reset: Last reset date:
(e) Loan Term 30 Year 25 Year 20 Year 15 Year 10 Year Other (please specify)
(f) Interest Rate Current Rate: Default Rate: Teaser Rate: Yes No
New York State Banking Department – Draft Form for Loans Subject to Pre-Foreclosure Notice – January 19, 2009
7. Loan Details (Continued)
(g) Amount Due and Owing on Loan
Principal Balance $
Interest $
Late Fees $
Other 3rd Party Charges $
Total $
(h) Current monthly payments $
(i) Does payment include escrow with taxes and insurance? Yes No
(j) How long has loan been delinquent? 1-30 days 31-60 days 61-90 days 91-120 days over 120 days
(k) Is loan in a Securitization Trust or SPV? Yes No
New York State Banking Department – Draft Form for Loans Subject to Pre-Foreclosure Notice – January 19, 2009