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					                 100 Prospect Street, Stamford, CT 06901  

Dear Homeowner,
HDF’S foreclosure intervention program is an effective solution for borrowers at risk of foreclosure or with an
unaffordable mortgage. HDF will try to help homeowners who are eligible for our program find solutions. A list of
eligibility requirements may be found below. You should consider all options while you are working with us. If you
believe you are harassed by debt collectors or that the debt collector is engaging in illegal or unethical activities, you
should contact the Federal Trade Commission at 1-877-FTC-HELP.

If you are in arrears on your mortgage loan, HDF may be able to assist you in working out a resolution with your lenders.
In order to be eligible you need to meet the following guidelines:

    1. You must live in the property
    2. You cannot own other property
    3. Your mortgage indebtedness may not exceed $729,750

HDF may be a resource for you if any of these conditions apply:

    1.   Mortgage loans are in delinquency
    2.   Mortgage loans are current but default is imminent or foreseeable
    3.   There is a pending rate reset within 6 months
    4.   There has been a material reduction in income
    5.   There has been an increase in debt
    6.   There has been a notice of foreclosure

Please contact HDF’s foreclosure hotline at 203 969-1830 ext. 31 and a representative will contact you regarding our
program and orientation sessions. Reservations are required. PLEASE NOTE: We can NOT accommodate children or
guests; only applicants and co-applicants who are registered in advance can be admitted.
HDF is a non-profit agency and does not charge a fee for our counseling service. We do however incur an expense for
ordering a credit report and request that you include a check or money order in the amount of $15.75 for one (1)
person and $16.50 for a joint report made out to Housing Development Fund, Inc.

Please bring copies of the following items (We CANNOT accept originals):
        Application form – filled out
        Copy of mortgage and note
        Copies of correspondence from your mortgage company
        Copy of your latest monthly mortgage statement
        One month of current paystubs for all employment
        Past two years of complete tax returns
        W-2 for past 2 years
        Verification of any other source of income
        Two months of bank statements
        Hardship Letter
        Current Utility bill(s)
                                                                                                        HDF FIC 1 Page 1 of 1
                                                                                                           October 2011
                           _______________________________ APPLICATION
 APPLICANT NAME                                                CO APPLICANT NAME

 SOCIAL SECURITY #________________________________             SOCIAL SECURITY #________________________________

 DATE OF BIRTH____________________________________             DATE OF BIRTH____________________________________

 EDUCATION (circle one) college grad degree some college       EDUCATION (circle one) college grad degree some college
 high school/GED none primary some college some high           high school/GED none primary some college some high
 school vocational                                             school vocational

 HOME PHONE____________________________________                HOME PHONE____________________________________

 WORK OR CELL PHONE_____________________________               WORK OR CELL PHONE_____________________________

 EMAIL___________________________________________       EMAIL___________________________________________
 ____                                                   ____________________________________
 HOUSEHOLD TYPE (circle one):
    Single Adult Single Parent Married with dependants Married without dependants Unrelated Adults Other
 PREFERRED LANGUAGE (circle one):   English      Spanish
 REFERRED BY (circle one): Mediator Web/Internet Gov Agency          Other Agency     Lender    News        Friend/Family
 Property Address:
 STREET: ____________________________________________________________________
 CITY: ____________________________STATE: _______________ ZIP:_________________
The following information is requested by the Federal Government to monitor compliance with Federal statutes that
prohibit discrimination in housing. You are not required to furnish this information, but are encouraged to do so.

 APPLICANT                                                  CO APPLICANT
     I do not wish to furnish this information                  I do not wish to furnish this information
 Ethnicity:   Hispanic or Latino                            Ethnicity:   Hispanic or Latino
              Not Hispanic or Latino                                     Not Hispanic or Latino
 Race:        American Indian or Alaska Native              Race:        American Indian or Alaska Native
              Asian                                                      Asian
              Black or African American                                  Black or African American
              Native Hawaiian or Other Pacific Islander                  Native Hawaiian or Other Pacific Islander
              White                                                      White
 Sex:         Female        Male                            Sex:         Female       Male

                                                                                       HDF FMC APPLICATION Page 1 of 7

                                                                                          October 2011
                           _______________________________ APPLICATION

Property Status: (this information is required for speedy processing)
The property is my:                     Primary Residence            Second Home Investment

The Property is:                        Single Family     Condo/Townhouse          Multi-family # units____

The Property is:                        Owner Occupied               Renter Occupied      Vacant

Is the Property Damaged? :                        Yes                       No

Did you get your current mortgage before January 1, 2009?            Yes                  No

Did you have to provide complete proof of income, employment etc. when you applied for this mortgage?           Yes No

Is the amount you owe on your first mortgage equal to or less than $729,750?              Yes                     No

I want to:                       Keep the Property        Sell the Property

Have you received a foreclosure notice from an attorney?       Yes                        No

Is the property listed for sale?            Yes                No
         If yes, have you received an offer?      Yes                 No
         If yes, please provide details:____________________________________________________________

Do you pay Condominium or HOA Fee?      Yes                          No

Have you filed for bankruptcy?         Yes                No
       If yes,    Chapter 7            Chapter 13             Filing Date:__________________
       Has your bankruptcy been discharged?               Yes    No Bankruptcy Case Number:__________________

I believe that my situation is   Short Term (< 6 months)             Long Term (> 6 months)         Permanent

Who pays the Real Estate Tax bill on your Home?           Bank pays                I do

Are the taxes current?           Yes                      No

Who pays the hazard insurance policy for your property?              Bank pays     I do

Is the policy current?           Yes                      No

Name of hazard insurance company ______________________________________________________________
                                                                           HDF FMC APPLICATION Page 2 of 7

                                                                                              October 2011
                         _______________________________ APPLICATION

                                     Mortgage Information (First Mortgage)
Holder (Bank or Servicer) _________________________________________________Loan #_________________________
Contact Name_________________________________________________________________________________________

        ADDRESS                                     CITY                                                      STATE              ZIP

                      PHONE                                           FAX                                   EMAIL
Monthly Payment TOTAL $: __________________________
Payment Breakdown:      Principal $________________ Interest $_______________________ Taxes $_______________Insurance $______________

Monthly Payment Status (circle one):
      Current        30-60 Days Late             60-90 Days Late               90-120 Days Late            120 or more Days Late

Current Interest Rate % ___________________________
Term (15 year, 20 year, 30 year, etc) _________________
Current Principal Balance $_________________________
Past Due Payment Amount $ _______________________

                        Mortgage Information (Second Mortgage, if Applicable)
Holder (Bank or Servicer) _________________________________________________Loan #_________________________

Contact Name_________________________________________________________________________________________

        ADDRESS                                     CITY                                                      STATE              ZIP

                      PHONE                                           FAX                                   EMAIL
Monthly Payment TOTAL $: __________________________
Payment Breakdown:      Principal $________________ Interest $_______________________

Monthly Payment Status (circle one):
      Current        30-60 Days Late             60-90 Days Late               90-120 Days Late            120 or more Days Late

Current Interest Rate % ___________________________
Term (15 year, 20 year, 30 year, etc) _________________
Current Principal Balance $_________________________
Past Due Payment Amount $ _______________________
                                                                                                    HDF FMC APPLICATION Page 3 of 7

                                                                                                       October 2011
                                      _______________________________ APPLICATION

Status HOA, Condo Association dues (if Applicable)
HOA/ Condo Association: _________________________________ ______________________________________________

Contact Name_________________________________________________________________________________________

ADDRESS                                                  CITY                                                            STATE                  ZIP

PHONE                                                    FAX                                     EMAIL

Monthly Common Charges & Assessments $: __________________

Monthly Payment Status (circle one):
                             Current       30-60 Days Late         60-90 Days Late             90-120 Days Late       120 or more Days Late

Past Due Payment Amount $ ______________________

Applicant Employment Information                                                          Co-Applicant Employment Information
Applicant Employer:                                                                       Co Applicant Employer:

Type of Business:                                                                         Type of Business:

Position:                                                                                 Position:

Date Started:                                                                             Date Started:

Gross Annual Income:                                                                      Gross Annual Income:

Net Annual Income:                                                                        Net Annual Income:

                                                                       HARDSHIP AFFIDAVIT
                 I (We) am/are having difficulty making my monthly mortgage payment(s) because of financial difficulties created by (check all that apply):

                My household income has been reduced. For example:                                My monthly debt payments are excessive and I am overextended
                unemployment, underemployment, reduced pay or hours,                              with my creditors. Debt includes credit cards, home equity or
                decline in business earnings, death, disability or divorce of a                   other debt.
                borrower or co-borrower.

                My expenses have increased. For example: monthly mortgage                         My cash reserves, including all liquid assets, are insufficient to
                payment reset, high medical or health care costs, uninsured                       maintain my current mortgage payment and cover basic living
                losses, increased utilities or property taxes.                                    expenses at the same time.

             OTHER (Please specify)

                                                                                                                          HDF FMC APPLICATION Page 4 of 7

                                                                                                                                 October 2011
                       _______________________________ APPLICATION

                       HOUSEHOLD INCOME and ASSETS
           Monthly Household Income                                         Household Assets*

      Monthly Gross Wages          $                              Checking Account(s)          $

      Overtime                     $                              Checking Account(s)          $

      Child Support/ Alimony       $                              Savings/ Money Market        $
                                                                  CDs                          $
      Social Security/SSDI         $
                                                                  Stocks/Bonds                 $
      Other monthly income         $
      from pensions, annuities                                    Other Cash on Hand           $
      or retirement plans
                                                                  Other Real estate            $
      Tips, commissions, bonus     $                              (estimated valus)
      and self-employed
                                                                  Other_______________         $

      Rents Received               $

      Unemployment Income          $

      Food Stamps/Welfare          $
                                                                  Other________________        $
      Other (investment            $
      income, royalties,
      interest, dividends, etc.)

      Total (Gross Income)         $                              Total Assets                 $
        Do

*Do not include the value of life insurance or retirement plans when calculating assets (401K, pension funds,
annuities, IRAs, Keogh plans, etc.)

                                                                                      HDF FMC APPLICATION Page 5 of 7

                                                                                        October 2011
                  _______________________________ APPLICATION

                              HOUSEHOLD EXPENSES-1
CATEGORY                                             MONTHLY $
Car Related
                  Car loan(s)
                  Car Insurance
                  Maintenance/ Repairs

House Related
                  Mortgage payment
                  Property Taxes
                  Homeowners insurance
                  Heating Oil
                  Water/ Sewer

Other Loans
                  Credit card min payments
                  Installment loans - excl. car(s)
                  Student loans
                  Other loans

Living Expenses
                  Dining Out
                  Food at Work

                  Cable TV
                  Telephone - land line
                  Cell phones

                                                                 HDF FMC APPLICATION Page 6 of 7

                                                                   October 2011
               _______________________________ APPLICATION

                       HOUSEHOLD EXPENSES -2
EXPENSE CATEGORY                             MONTHLY $
Children           Child care
                   Child support/ Allimony
                   School fees/ books &
                   School lunches

                   Medical Insurance

                   Church donations
                   Life Insurance

                       TOTAL EXPENSES        $

                    TOTAL GROSS INCOME
                     (from page 5 above)     $
                      SURPLUS/DEFICIT        $

                                                         HDF FMC APPLICATION Page 7 of 7

                                                           October 2011
                           A HUD Approved Housing Counseling Agency

                        ____________APPLICANT’S CERTIFICATION AND AUTHORIZATION

The undersigned certify and authorize the following:
The foreclosure intervention process includes the application, and additional forms Housing Development Fund may
require, including Credit Release Form, Authorization to Lender and other forms. HDF cannot accept my application
unless the forms in the Foreclosure Intervention package are completed.

In applying I (we) have completed an application containing various information and forms relating to employment,
family members income information, and assets and liabilities. I (we) certify that all of the information is true and
complete. I (we) made no misrepresentation in the application, nor in other documents nor did I (we) omit pertinent

I (we) fully understand and agree that HDF reserves the right to verify any information provided to them. In writing I
(we) authorize HDF and its representatives to speak on my behalf regarding my mortgage with the lender and the

I (we) understand that HDF receives funding through NFMC, the Housing Partnership Network, the United Way and the
Connecticut Housing Finance Authority (CHFA). HDF is required to share some of my personal information with Housing
Partnership Network, the United Way, CHFA and their agents, administrators, and/or government representatives for
purposes of oversight, compliance and evaluation.

A copy of this certification and authorization may be used as an original.

I (we) fully understand that HDF will provide recommendations, information and counseling. HDF makes no decision in
the resolution of the mortgage loan, and I (we) are free to choose which program suits me. I (we) also understand that
the lender/servicer makes the ultimate decision.

APPLICANT NAME (PRINT)                           APPLICANT SIGNATURE                              DATE

CO-APPLICANT NAME (PRINT)                        CO-APPLICANT SIGNATURE                           DATE

Counselor’ Name                      Counselor’s Signature                       Counselor’s Email Address

                                                Housing Development Fund
                                               100 Prospect Street Suite 100
                                                    Stamford, Ct 06901
                                                   203-969-1830, ext 21
                                                    203-323-8958 FAX
                                                                                     HDF FIC3 CERTIFICATION Page 1 of 1
                                                                                     October 2011
                      _________Foreclosure Mitigation Counseling Agreement
1.      I (WE) understand that Housing Development Fund, Inc. (HDF) provides foreclosure
mitigation counseling after which I (WE) will receive a written action plan consisting of
recommendations for handling MY/OUR finances, possibly including referrals to other housing
agencies, as appropriate.

2.     I(WE) understand that HDF receives Congressional funds through the National
Foreclosure Mitigation Counseling (NFMC) program and, as such, is required to share some of
MY/OUR personal information with NFMC program administrators or their agents for purposes
of program monitoring, compliance and evaluation.

3.     I (WE) give permission for NFMC Administrators and/or their agents to follow-up with
me(us) between now and December 31, 2013 for the purposes of program evaluation.

4.      I (WE)understand that I (WE) may be referred to other housing services of the
organization or another agency or agencies as appropriate that may be able to assist with
particular concerns that have been identified. I (WE) understand that I (WE) am not obligated to
use any of the services offered to me.

5.     A counselor may answer questions and provide information, but not give legal advice.

6.     I (WE) understand that Housing Development Fund, Inc. provides information and
education on numerous loan products and housing programs and I (WE) further understand
that the housing counseling I (WE) receive from HDF in no way obligates me to choose any of
these particular loan products or housing programs.

7.     I (WE) acknowledge that we have received a copy of HDF’s Privacy Policy.

CLIENT NAME (PRINT)                 CLIENT SIGNATURE                   DATE

CLIENT NAME (PRINT)                 CLIENT SIGNATURE                   DATE

                                                               HDF FIC4 Counseling Agreement Page 1 of 1
                                                               October 2011
                        ________________________________________CREDIT RELEASE FORM


FIRST                             MIDDLE                                LAST

CO-APPLICANT NAME (if applicable)

FIRST                             MIDDLE                                LAST


HOUSE NUMBER                                    CITY                                             STATE          ZIP


HOUSE NUMBER                                    CITY                                             STATE          ZIP

Social Security # of Applicant:

Social Security # of Co-Applicant:

By signing below, I (WE) AUTHORIZE the Housing Development Fund to order my credit report.

By signing below, I (WE) authorize the Housing Development Fund to run a credit check when necessary, and to
release all information to interested parties upon their request.

APPLICANT NAME (PRINT)                                 APPLICANT SIGNATURE                         DATE

CO-APPLICANT NAME (PRINT)                              CO-APPLICANT SIGNATURE                      DATE

FEE: $15.75 for one (1) person and $16.50 for a joint report. Check or Money Order only for Credit Report (no cash).
Make checks payable to Housing Development Fund.

                                         THIS BOX FOR HDF USE
    Amount Received: _______________________________ Date: _________________________
    Number of Single Credit Reports: ______
    Number of Joint Credit Reports: ______
                                                                               HDF FIC5 CREDIT RELEASE FORM Page 1 of 1
                                                                                                            October 2011
                              _________AUTHORIZATION TO RELEASE INFORMATION

TO: __________________________________________________________________________

RE: ___________________________________________________________________________
                 BORROWER                           LOAN #

Dear ____________

        I (We) are working with Housing Development Fund, Inc. (a HUD certified counseling agency) on
a plan to resolve our mortgage delinquency. I (We) hereby authorize you to release any and all
information concerning our account to the Housing Development Fund, Inc. at their request.

       I (We) further authorize you to discuss our case with Housing Development Fund, Inc.
counselors who are working to help us address our financial problems and to propose a loss mitigation
plan which is within your guidelines.

         Thank you for taking the time to deal with this request.

Very truly yours,

____________________________________________________                         DATE_____________

____________________________________________________                        DATE______________

                                        HDF FIC6 AUTHORIZATION TO RELEASE INFORMATION Page 1 of 1
                                        October 2011
                        ______________________________________PRIVACY POLICY
Housing Development Fund, Inc. (HDF) is committed to assuring the privacy of individuals and/or
families who have contacted us for assistance. We realize that the concerns you bring to us are highly
personal in nature. We assure you that all information shared both orally and in writing will be
managed within legal and ethical considerations. Your “nonpublic personal information,” such as your
total debt information, income, living expenses and personal information concerning your financial
circumstances, will be provided to creditors, program monitors, and others only with your authorization
and signature on the Foreclosure Mitigation Counseling Agreement. We may also use anonymous
aggregated case file information for the purpose of evaluating our services, gathering valuable research
information and designing future programs.


. Information we receive from you orally, on applications or other forms, such as your name, address,
social security number, assets and income;

. Information about your transactions with us, your creditors, or others, such as your account balance,
payment history, parties to transactions and credit card usage; and

. Information we receive from a credit reporting agency, such as your credit history.


    1. You have the opportunity to “opt-out” of disclosures of your nonpublic personal information to
       third parties (such as your creditors), that is, direct us not to make those disclosures.
    2. If you choose to “opt-out”, we will not be able to answer questions from your creditors. If at
       any time, you wish to change your decision with regard to your “opt-out”, you may call us at
       203-969-1830 EXT 31 and do so.


    1. So long as you have not opted-out, we may disclose some or all of the information that we
       collect, as described above, to your creditors or third parties where we have determined that it
       would be helpful to you, would aid us in counseling you, or is a requirement of grant awards
       which make our services possible.
    2. We may also disclose any nonpublic personal information about you or former customers to
       anyone as permitted by law (e.g. if we are compelled by legal process).
    3. Within the organization, we restrict access to nonpublic personal information about you to
       those employees who need to know that information to provide services to you. We maintain
       physical, electronic and procedural safeguards that comply with federal regulations to guard
       your nonpublic personal information.

                                                                    HDF FIC7 PRIVACY POLICY Page 1 of 1
                                                                    October 2011

Directions to Stamford Office (100 Prospect Street, Suite 100)                        Phone (203) 969-1830
         From Interstate 95 North:
           Take Exit 8 off of I-95 North
           Turn left onto Atlantic Street.
           See directions below
         From Interstate 95 South:
           Take Exit 8 off of I-95 South.
           Go straight - through 2 traffic lights.
           At 3rd traffic light, turn right onto Atlantic Street.
           See directions below

         From I-95 North or South above:
           Go straight on Atlantic Street - through 3 traffic lights to intersection with Broad Street
           Go straight through traffic light - Atlantic Street becomes Bedford Street at this point.
           Keep going straight through one more traffic light. At next light, turn right onto North Street and go to
             end of North Street where it intersects with Prospect Street.
           100 Prospect Street is at corner of North and Prospect Streets on your right. Turn right onto Prospect
             Street and enter garage on your right at 100 Prospect Street.
           Park in area designated for visitors. Walk up the ramp to exit the garage onto Prospect Street. Turn left
             and walk towards the corner of Prospect and North. Turn left again towards North.
           Our offices are located immediately on your left; walk up the ramp and enter through the glass door.
             Please note that this is a construction site, apologies for the minimal signage.

Directions to Bridgeport Office (940 Broad Street)                                    Phone: (203) 338-9035
         From Interstate 95 North:
           Merge onto I-95 N via the ramp to New Haven
           Take exit 26 for Wordin Ave
           Turn left at Wordin Ave
           Turn right at State St
           Turn right at Broad St
           Destination will be on the left , directly across from the library
         From Interstate 95 South:
             Merge onto I-95 S toward NY City
             Take exit 27 to merge onto Lafayette Blvd
             Turn right at State St
             Turn right at Broad St

         There is metered parking on Broad Street and the entrance is on 940 Broad Street.

                                                                                     HDF FIC7 DIRECTIONS Page 1 of 2
                                                                                    October 2011

Directions to Danbury Office (8 West Street, Suite 202-204)                             Phone: (203) 798-6527

   From Interstate 84 East:
        Take Exit 5
        Go through stop sign to light at bottom of hill
        Turn right on Main Street
        Go through five lights to intersection of West Street
        See office directions below

   From Interstate 84 West:
        Take Exit 5
        At end of ramp, turn right on Main Street
        Proceed through six lights to West Street
        See office directions below

   To Office Directions:
        Turn right on West Street
        8 West Street is immediately on your left next to the Danbury Public Library
        On-street parking is available on West Street
        Once you enter the building, take the elevator to the second floor.
        Proceed to Suite 202-204

                                                                                    HDF FIC7 DIRECTIONS Page 2 of 2
                                                                                   October 2011
Dodd-Frank Certification
The following information is requested by the federal government in accordance with the Dodd-
Frank Wall Street Reform and Consumer Protection Act (Pub. L. 111-203). You are required
to furnish this information. The law provides that no person shall be eligible to receive
assistance from the Making Home Affordable Program, authorized under the Emergency
Economic Stabilization Act of 2008 (12 U.S.C. 5201 et seq.), or any other mortgage assistance
program authorized or funded by that Act, if such person, in connection with a mortgage or real
estate transaction, has been convicted, within the last 10 years, of any one of the following: (A)
felony larceny, theft, fraud or forgery, (B) money laundering or (C) tax evasion.

                   Borrower                                         Co-Borrower
    I have not been convicted within the last       I have not been convicted within the last
     10 years of any one of the following in          10 years of any one of the following in
     connection with a mortgage or real               connection with a mortgage or real
     estate transaction:                              estate transaction:
     (a) felony larceny, theft, fraud or forgery,     (a) felony larceny, theft, fraud or forgery,
     (b) money laundering or                          (b) money laundering or
     (c) tax evasion                                  (c) tax evasion

In making this certification, I/we certify under penalty of perjury that all of the information in this
document is truthful and that I/we understand that the Servicer, the U.S. Department of the
Treasury, or their agents may investigate the accuracy of my statements by performing routine
background checks, including automated searches of federal, state and county databases, to
confirm that I/we have not been convicted of such crimes. I/we also understand that knowingly
submitting false information may violate Federal law.

______________________________________                                 ___________
Borrower Signature                                                           Date

______________________________________                                 ___________
Co-Borrower Signature                                                        Date

                                                                                October 2011
Form    4506-T                                            Request for Transcript of Tax Return
(Rev. January 2011)                                                                                                                                       OMB No. 1545-1872

Department of the Treasury
                                                      ▶   Request may be rejected if the form is incomplete or illegible.
Internal Revenue Service

Tip. Use Form 4506-T to order a transcript or other return information free of charge. See the product list below. You can quickly request transcripts by using
our automated self-help service tools. Please visit us at and click on "Order a Transcript" or call 1-800-908-9946. If you need a copy of your return, use
Form 4506, Request for Copy of Tax Return. There is a fee to get a copy of your return.

   1a Name shown on tax return. If a joint return, enter the name shown                        1b First social security number on tax return, individual taxpayer identification
      first.                                                                                      number, or employer identification number (see instructions)

   2a If a joint return, enter spouse’s name shown on tax return.                              2b Second social security number or individual taxpayer
                                                                                                  identification number if joint tax return

   3 Current name, address (including apt., room, or suite no.), city, state, and ZIP code (See instructions)

   4 Previous address shown on the last return filed if different from line 3 (See instructions)

   5 If the transcript or tax information is to be mailed to a third party (such as a mortgage company), enter the third party’s name, address,
     and telephone number. The IRS has no control over what the third party does with the tax information.

Caution. If the transcript is being mailed to a third party, ensure that you have filled in line 6 and line 9 before signing. Sign and date the form once you
have filled in these lines. Completing these steps helps to protect your privacy.

   6     Transcript requested. Enter the tax form number here (1040, 1065, 1120, etc.) and check the appropriate box below. Enter only one tax form
         number per request. ▶
    a    Return Transcript, which includes most of the line items of a tax return as filed with the IRS. A tax return transcript does not reflect
         changes made to the account after the return is processed. Transcripts are only available for the following returns: Form 1040 series,
         Form 1065, Form 1120, Form 1120A, Form 1120H, Form 1120L, and Form 1120S. Return transcripts are available for the current year
         and returns processed during the prior 3 processing years. Most requests will be processed within 10 business days . . . . . .

    b    Account Transcript, which contains information on the financial status of the account, such as payments made on the account, penalty
         assessments, and adjustments made by you or the IRS after the return was filed. Return information is limited to items such as tax liability
         and estimated tax payments. Account transcripts are available for most returns. Most requests will be processed within 30 calendar days. .
    c    Record of Account, which is a combination of line item information and later adjustments to the account. Available for current year and
         3 prior tax years. Most requests will be processed within 30 calendar days . . . . . . . . . . . . . . . . . . .
   7     Verification of Nonfiling, which is proof from the IRS that you did not file a return for the year. Current year requests are only available
         after June 15th. There are no availability restrictions on prior year requests. Most requests will be processed within 10 business days . .
   8     Form W-2, Form 1099 series, Form 1098 series, or Form 5498 series transcript. The IRS can provide a transcript that includes data from
         these information returns. State or local information is not included with the Form W-2 information. The IRS may be able to provide this
         transcript information for up to 10 years. Information for the current year is generally not available until the year after it is filed with the IRS.
         For example, W-2 information for 2007, filed in 2008, will not be available from the IRS until 2009. If you need W-2 information for retirement
         purposes, you should contact the Social Security Administration at 1-800-772-1213. Most requests will be processed within 45 days . . .
Caution. If you need a copy of Form W-2 or Form 1099, you should first contact the payer. To get a copy of the Form W-2 or Form 1099 filed
with your return, you must use Form 4506 and request a copy of your return, which includes all attachments.

   9     Year or period requested. Enter the ending date of the year or period, using the mm/dd/yyyy format. If you are requesting more than four
         years or periods, you must attach another Form 4506-T. For requests relating to quarterly tax returns, such as Form 941, you must enter
         each quarter or tax period separately.

Signature of taxpayer(s). I declare that I am either the taxpayer whose name is shown on line 1a or 2a, or a person authorized to obtain the tax
information requested. If the request applies to a joint return, either husband or wife must sign. If signed by a corporate officer, partner, guardian, tax
matters partner, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify that I have the authority to execute
Form 4506-T on behalf of the taxpayer. Note. For transcripts being sent to a third party, this form must be received within 120 days of signature date.
                                                                                                                     Telephone number of taxpayer on
                                                                                                                     line 1a or 2a
            ▲ ▲ ▲

                    Signature (see instructions)                                                            Date
Here                Title (if line 1a above is a corporation, partnership, estate, or trust)

                    Spouse’s signature                                                                      Date
For Privacy Act and Paperwork Reduction Act Notice, see page 2.                                              Cat. No. 37667N                        Form 4506-T (Rev. 1-2011)
Form 4506-T (Rev. 1-2011)                                                                                                                              Page   2

General Instructions                                  Chart for all other transcripts                         Corporations. Generally, Form 4506-T can be
                                                                                                           signed by: (1) an officer having legal authority to
Purpose of form. Use Form 4506-T to request           If you lived in             Mail or fax to the       bind the corporation, (2) any person designated
tax return information. You can also designate a      or your business            “Internal Revenue        by the board of directors or other governing
third party to receive the information. See line 5.   was in:                     Service” at:             body, or (3) any officer or employee on written
Tip. Use Form 4506, Request for Copy of                                                                    request by any principal officer and attested to
Tax Return, to request copies of tax returns.         Alabama, Alaska,                                     by the secretary or other officer.
                                                      Arizona, Arkansas,
Where to file. Mail or fax Form 4506-T to                                                                     Partnerships. Generally, Form 4506-T can be
                                                      California, Colorado,
the address below for the state you lived in,                                                              signed by any person who was a member of the
                                                      Florida, Hawaii, Idaho,
or the state your business was in, when that                                                               partnership during any part of the tax period
                                                      Iowa, Kansas,
return was filed. There are two address charts:                                                            requested on line 9.
                                                      Louisiana, Minnesota,
one for individual transcripts (Form 1040 series      Mississippi,                                            All others. See Internal Revenue Code section
and Form W-2) and one for all other transcripts.      Missouri, Montana,                                   6103(e) if the taxpayer has died, is insolvent, is a
   If you are requesting more than one transcript     Nebraska, Nevada,           RAIVS Team               dissolved corporation, or if a trustee, guardian,
or other product and the chart below shows two        New Mexico,                 P.O. Box 9941            executor, receiver, or administrator is acting for
different RAIVS teams, send your request to the       North Dakota,               Mail Stop 6734           the taxpayer.
team based on the address of your most recent         Oklahoma, Oregon,           Ogden, UT 84409          Documentation. For entities other than
return.                                               South Dakota, Texas,                                 individuals, you must attach the authorization
                                                      Utah, Washington,                                    document. For example, this could be the letter
Automated transcript request. You can quickly
                                                      Wyoming, a foreign                                   from the principal officer authorizing an
request transcripts by using our automated self
                                                      country, or A.P.O. or                                employee of the corporation or the Letters
help-service tools. Please visit us at and
                                                      F.P.O. address              801-620-6922             Testamentary authorizing an individual to act for
click on “Order a Transcript” or call
1-800-908-9946.                                                                                            an estate.
Chart for individual                                  Delaware, District of                                Privacy Act and Paperwork Reduction Act
                                                      Columbia, Georgia,                                   Notice. We ask for the information on this form
transcripts (Form 1040 series and                     Illinois, Indiana,                                   to establish your right to gain access to the
Form W-2)                                             Kentucky, Maine,                                     requested tax information under the Internal
                                                      Maryland,                                            Revenue Code. We need this information to
If you filed an             Mail or fax to the        Massachusetts,                                       properly identify the tax information and respond
                                                      Michigan, New               RAIVS Team
individual return           “Internal Revenue                                     P.O. Box 145500          to your request. You are not required to request
and lived in:               Service” at:              Hampshire, New                                       any transcript; if you do request a transcript,
                                                      Jersey, New York,           Stop 2800 F
                                                                                  Cincinnati, OH 45250     sections 6103 and 6109 and their regulations
Florida, Georgia (After     RAIVS Team                North Carolina,                                      require you to provide this information, including
June 30, 2011, send         P.O. Box 47-421           Ohio, Pennsylvania,                                  your SSN or EIN. If you do not provide this
your transcript             Stop 91                   Rhode Island, South                                  information, we may not be able to process your
requests to Kansas          Doraville, GA 30362       Carolina, Tennessee,                                 request. Providing false or fraudulent information
City, MO)                   770-455-2335              Vermont, Virginia,                                   may subject you to penalties.
                                                      West Virginia,
                                                      Wisconsin                   859-669-3592                 Routine uses of this information include giving
Alabama, Kentucky,          RAIVS Team                                                                     it to the Department of Justice for civil and
Louisiana, Mississippi,     Stop 6716 AUSC                                                                 criminal litigation, and cities, states, the District
                                                      Line 1b. Enter your employer identification
Tennessee, Texas, a         Austin, TX 73301                                                               of Columbia, and U.S. commonwealths and
                                                      number (EIN) if your request relates to a
foreign country,                                                                                           possessions for use in administering their tax
                                                      business return. Otherwise, enter the first
American Samoa,                                                                                            laws. We may also disclose this information to
                                                      social security number (SSN) or your individual
Puerto Rico, Guam, the                                                                                     other countries under a tax treaty, to federal and
                                                      taxpayer identification number (ITIN) shown on
Commonwealth of the                                                                                        state agencies to enforce federal nontax criminal
                                                      the return. For example, if you are requesting
Northern Mariana                                                                                           laws, or to federal law enforcement and
                                                      Form 1040 that includes Schedule C (Form
Islands, the U.S. Virgin    512-460-2272                                                                   intelligence agencies to combat terrorism.
                                                      1040), enter your SSN.
Islands, or A.P.O. or
F.P.O. address                                        Line 3. Enter your current address. If you use a         You are not required to provide the
                                                      P. O. box, include it on this line.                  information requested on a form that is subject
                                                                                                           to the Paperwork Reduction Act unless the form
Alaska, Arizona,            RAIVS Team                Line 4. Enter the address shown on the last          displays a valid OMB control number. Books or
Arkansas, California,       Stop 37106                return filed if different from the address entered   records relating to a form or its instructions must
Colorado, Hawaii,           Fresno, CA 93888          on line 3.                                           be retained as long as their contents may
Idaho, Illinois, Indiana,                                                                                  become material in the administration of any
Iowa, Kansas,                                         Note. If the address on Lines 3 and 4 are
                                                                                                           Internal Revenue law. Generally, tax returns and
Michigan, Minnesota,                                  different and you have not changed your address
                                                                                                           return information are confidential, as required by
Montana, Nebraska,                                    with the IRS, file Form 8822, Change of Address.
                                                                                                           section 6103.
Nevada, New Mexico,                                   Line 6. Enter only one tax form number per
North Dakota,                                                                                                  The time needed to complete and file Form
Oklahoma, Oregon,           559-456-5876                                                                   4506-T will vary depending on individual
                                                      Signature and date. Form 4506-T must be              circumstances. The estimated average time is:
South Dakota, Utah,                                   signed and dated by the taxpayer listed on line
Washington,                                                                                                Learning about the law or the form, 10 min.;
                                                      1a or 2a. If you completed line 5 requesting the     Preparing the form, 12 min.; and Copying,
Wisconsin, Wyoming                                    information be sent to a third party, the IRS must   assembling, and sending the form to the IRS,
                                                      receive Form 4506-T within 120 days of the date      20 min.
Connecticut, Delaware,      RAIVS Team                signed by the taxpayer or it will be rejected.
                                                                                                               If you have comments concerning the
District of Columbia,       Stop 6705 P-6                Individuals. Transcripts of jointly filed tax     accuracy of these time estimates or suggestions
Maine, Maryland,            Kansas City, MO           returns may be furnished to either spouse. Only      for making Form 4506-T simpler, we would be
Massachusetts,              64999                     one signature is required. Sign Form 4506-T          happy to hear from you. You can write to the
Missouri, New                                         exactly as your name appeared on the original        Internal Revenue Service, Tax Products
Hampshire, New                                        return. If you changed your name, also sign your     Coordinating Committee, SE:W:CAR:MP:T:T:SP,
Jersey, New York,                                     current name.                                        1111 Constitution Ave. NW, IR-6526,
North Carolina, Ohio,                                                                                      Washington, DC 20224. Do not send the form to
Pennsylvania, Rhode                                                                                        this address. Instead, see Where to file on this
Island, South Carolina,                                                                                    page.
Vermont, Virginia, West     816-292-6102

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