Fraud Stoppers Intake Form

Please select the loan
advocate or referral source


Basic Info
Homeowner First Name
Homeowner Last Name
Co-owner First Name
Co-owner Last Name
File Type
Which services are requested?
How did you hear about us?
Phone number
 -    -    Ext #
Cell number  -    -  
Property Info
Property Address
Property City
Property State
Property Zip
Property Type
What is the current estimated value of your home?
How many years have you lived in the property?
Do you want to stay in this home?

Mortgage Info
Loan Origination Date

Loan Origination Amount
Monthly Loan Payment
Original Lender
Current Lender/servicer
What is the estimated balance for the 1st mortgage?
Is there a 2nd lender?

Is the mortgage currently behind?

Have you received a notice of foreclosure?

Have you already received or tried to receive
a modification/ forbearance/work out from your bank?

Mortgage Notes