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Call Center Mortgage Inquiry Form

Helps call center agents record a caller's mortgage situation and schedule a follow-up appointment.

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Date of Call

Full Name

First Name

Last Name

E-mail

Phone Number

Address

Street Address

City

State / Province

ZIP / Postal Code

Good Time to Call Back (Only if They Said 'No' and Can't Talk Now)

1. Are You Behind on Any of Your Mortgage Payments? If Yes, Include How Many Months in 'Other'

Yes No Other

2. Is the Mortgage You Are Having Problems With Your Primary Residence?

Yes No

3. Do You Believe That the Amount You Owe on Your Mortgage(s) Is Greater Than the Current Value of Your Home?

Yes No Not Sure

4. Have You Received a Foreclosure Notice From Your Lender?

Yes No

5. Are You Currently in Bankruptcy?

Yes No

6. Have You Attempted to Refinance or Modify Your Loan and Been Denied or Could Not Complete the Revised Payments?

Yes No

7. Would You Like to Keep Your Home?

Yes No

Preferred Appointment Day

Appointment Time Info or Any Other Help Notes from Caller

Call Center: 'And Is (Number Already Provided) the Best Number to Reach You?'

Yes No

Alternate Phone Number

If Yes to Email Then Select Here

Yes No

Additional Comments

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