BAI Intake Form - PRF Institute

Part 1 - CLIENT INFORMATION

Full Name *

First

Middle

Last

Mailing Address *

Address Line 1

City

State

Zip Code

Full Name of Spouse (if applicable)

First

Middle

Last

Part 2 - CONTACT INFORMATION

Phone (cell/home) *

Phone (work)

Preferred method of contact *

Call
Text
Email
Any

Part 3 - PROPERTY/MORTGAGE INFORMATION

Property Address

Address Line 1

Address Line 2

City

State

Zip Code

Do not forget to include the COUNTY for this address.

1. How much is your mortgage payment?

2. When was the last time your mortgage was paid?

Month and Year

3. Is the mortgage for this property in your name?

Yes
No
I'm not sure

4. Is the mortgage for this property ALSO in your SPOUSE's name?

5. Is the deed (title) for this property in your name?

Yes
No
I'm not sure

6. Have you received a notice of foreclosure from an attorney, law office, or mortgage company?

* If YES, please attach a copy.

Click or drag files to this area to upload. You can upload up to 5 files.

7. Do you need assistance filing for Chapter 13 bankruptcy (repayment plan)? *

8. When is your home/property scheduled for foreclosure sale (auction)?

NEXT STEPS

Now that you have made this decision or are strongly considering it, PRF Institute understands the urgent timely nature of stopping the foreclosure process. Anyone considering filing for bankruptcy will need to provide the court with a list of creditors. As a next step, please provide a list of creditors’ names and addresses (no account numbers needed) on page #2. Please begin with the mortgage company attempting to foreclose on your property.

Part 4 - CREDITOR INFORMATION

Enter the following in the spaces below for each of your creditors. This will be needed to prepare your paperwork.: 1) Creditor(s) Name and 2) Creditor(s) Address, City, State, and Zip Code

** Mortgage Company

Loans, Credit Cards, Car Payments, Medical Bills, Title Pawns, Pay Day Loans, etc.

Signature and Processing Fee Required

I understand that submitting this form alone will not stop the foreclosure process. My signature below reflects that I/we authorize PRF Institute to review the information submitted to determine my eligibility to participate in its Bankruptcy Assistance Initiative.

Processing Fee

Price: $ 25.00

Credit or Debit Card *

Card

Name on Card

CVV/CVC Code *

Zip Code *

Provide the zip code associated with the billing address for this card.

Your Signature *

Spouse's Signature (if applicable)