What financial or legal obligation are you seeking assistance with? What financial or legal obligation are you seeking assistance with? Mortgage paymentsRentMedical billsJury duty What is your name? If you are writing this letter on someone else's behalf, enter their name instead of yours. Would you like to add your phone number and/or email address to this letter? Would you like to add your phone number and/or email address to this letter? YesNo Enter your phone number: If you only want to enter your email address, leave this field blank. Enter your email address: If you only want to enter your phone number, leave this field blank. Address What is your mailing address? Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Rental or Mortgage Property Is the address of the rental property the same as your mailing address? Is the address of the rental property the same as your mailing address? YesNo Is the address of the mortgaged property the same as your mailing address? Is the address of the mortgaged property the same as your mailing address? YesNo Obligation Details How much is your current monthly rent? $ How much is your current monthly rent? $ What is the address of the rental property? Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code How much is your total medical bill? $ When did you receive the services you've been billed for? How much is your current monthly mortgage payment? $ How much is your current monthly mortgage payment? $ What is the address of the mortgaged property? Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code When did you receive your jury summons? What is your assigned juror ID number? This number is usually found at the top of the jury summons. Bill Information What is the account number included on the medical bill? What is the date of the medical bill? Enter the date that the bill was sent, NOT the date on which the money is due. Recipient What is the name of the financial institution your letter is addressed to? This is most likely your mortgage servicer or lender. Is your letter addressed to a particular employee or agent of the financial institution? Is your letter addressed to a particular employee or agent of the financial institution? YesNo Enter the employee or agent's name: Are you writing this letter to an individual landlord or business entity? Are you writing this letter to an individual landlord or business entity? IndividualBusiness Entity What is the business entity's name? This should be the official company name used by the business in its correspondence. What is the landlord's name? What is the name of the healthcare provider that sent the bill? If your letter is addressed to a billing service instead of the original healthcare provider, enter the billing company's name. What is the name of the court you have been summoned to? Recipient Address Do you want to enter the recipient's mailing address at this time? Do you want to enter the recipient's mailing address at this time? YesNo What is the financial institution's mailing address? Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code What is the entity's mailing address? Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code What is the landlord's mailing address? Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code What is the healthcare provider or billing company's mailing address? Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code What is the court's mailing address? Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code If your jury summons lists a different address that is used specifically for jury services, use this address instead. Hardship What is the hardship that is causing you to seek relief? What is the hardship that is causing you to seek relief? Job Loss or Reduction in HoursSerious Illness or InjuryDivorce or Separation from SpouseDeath of a Loved OneArmed Forces DeploymentNatural or Man-Made DisasterLegal IssuesOther If you have experienced more than one hardship, select the one that has had the biggest impact on your ability to meet your obligations. Hardship Description Describe the hardship that is causing you to seek relief. I am seeking assistance because... This description should include details about the work that you do, when the job loss or reduction in hours occurred, and what financial impact this development has had on your household. Be as specific as possible in describing this financial impact. Describe the hardship that is causing you to seek relief. I am seeking assistance because... This description should include details about the nature of the illness or injury that occurred, when the injury occurred or the illness developed, and what financial impact this development has had on your household. Be as specific as possible in describing this financial impact. Describe the hardship that is causing you to seek relief. I am seeking assistance because... This description should explain when the divorce or separation process began and what financial impact this process has had on your household. Be as specific as possible in describing this financial impact. Describe the hardship that is causing you to seek relief. I am seeking assistance because... This description should include the name of the person who died, their relationship to you, when the death occurred, and what financial impact their death has had on your household. Be as specific as possible in describing this financial impact. Describe the hardship that is causing you to seek relief. I am seeking assistance because... This description should explain which member of your household has been deployed, when their deployment occurred or will occur, and what financial impact the deployment has had or will have on your household. Be as specific as possible in describing this financial impact. Describe the hardship that is causing you to seek relief. I am seeking assistance because... This description should include details about the disaster, how you were affected by it, and what financial impact it has had on your household. Be as specific as possible in describing this financial impact. Describe the hardship that is causing you to seek relief. I am seeking assistance because... This description should explain the legal issues you or a member of your household are facing, when they began, how long they are likely to persist, and what financial impact they have had on your household. Be as specific as possible in describing this financial impact. Describe the hardship that is causing you to seek relief. I am seeking assistance because... This description should include details about the hardship facing you or a member of your household, when the hardship occurred, and what financial impact it has had on your household. Be as specific as possible in describing this financial impact. Household Information What percentage of your household's income do you provide in a typical month? % What is the combined monthly income of all the working members of your household? $ What is the total amount of your household's typical monthly expenses? $ Employment What is the nature of your employment? What is the nature of your employment? Self-employed/independent contractorBusiness ownerPart- or full-time employee Employment Details What is the full legal name of your business? How many employees does the business have? employees How are you typically employed? If you work in a variety of jobs, choose the one in which you work the most frequently. Where are you employed? How many employees, including yourself, are in the division you work in? employee(s) If you are the only person in your division or group, write "one." Will your employer pay you for time spent serving on a jury? Will your employer pay you for time spent serving on a jury? NoYes Ask your employer what the company's policy is about payment for days spent on jury duty How many days of jury service will your employer pay you for? Enter the number followed by the word "day" or "days" depending on the policy. For example, write "three days" if your employer will compensate you for three days of jury service, but write "one day" if your employer will only cover one day of service. Payment Plan Describe your proposed alternative payment plan, beginning with "I propose the following modification: " Common modifications include extending the term of the loan or temporarily reducing monthly payments, with the difference being made up on future payments. Be sure to specify when your proposed alternative plan would begin and end, and what your new payment amounts would be. Describe your proposed alternative payment plan, beginning with "I propose the following modification: " Common modifications include temporarily reducing monthly payments or skipping one or more rent payments. Be sure to specify when your proposed alternative plan would begin and end, and how you intend to make up for any skipped or reduced payments after your hardship has ended. Describe your proposed alternative payment plan, beginning with "I propose the following modification: " Common modifications include temporarily pausing payments or making smaller monthly payments over a longer period of time. Be sure to specify when your proposed alternative plan would begin and end, and how you intend to make up for any reduced payments after your hardship has ended. Supporting Documentation Are you including any supporting documentation with your letter? Are you including any supporting documentation with your letter? YesNo Common supporting documents include copies of banking statements, medical or legal bills, or termination notices. What documents are you including with your letter? If you are including multiple forms of documentation, use commas to separate them in your answer. For example, "a bank statement, my medical bill, and a letter from my employer" Date On what date are you sending this letter? Next Save Save and finish later
