MEDIATION INFORMATION FORM STATE OF CONNECTICUT SUPERIOR COURT JD-CV-125 New 8-11 C.G.S. § 49-31l, PA 11-201 JUDICIAL BRANCH www.jud.ct.gov Instructions: This form is 3 pages. Please read this instruction section before filling out pages 2 and 3. The Foreclosure Mediation Program is set up to help homeowners and lenders reach a fair and voluntary agreement. By giving information about your financial situation on this form, you and your lender will be able to have a productive discussion about what may be available to you. What you must do: 1. Fill out the Appearance form and Foreclosure Mediation Certificate. These forms are included in this packet. You must file them with the court no later than 15 days after the return date. The return date is printed on the upper right part of the Summons form in this packet. You do not have to come to court on the return date. The court cannot notify you of the date and time you must come for your first mediation session until you file these forms. 2. Fill out this Mediation Information Form, attach the required paperwork, and send it all to the Plaintiff's attorney at the address of the attorney or law firm on the Summons form. Only one form should be filled out for each household. The paperwork you must send with this Mediation Information Form is listed on page 3 of this form. You must send it all to the lender's attorney as soon as possible, but at least 15 business days (about 3 weeks) before the first mediation session. Do not wait until you get the court notice of the date of the first mediation session to send this form and paperwork to the plaintiff's attorney. 3. Keep a copy of the filled-out Mediation Information Form and the paperwork. Bring the copy of the filled-out form and the paperwork to the first mediation session. Do not mail them to the court. What your lender must do: At least 15 days before the first mediation session, your lender will provide you with (1) contact information for someone at your mortgage company who is able to process your request for a loan workout, including their direct telephone number, fax number, email address and mailing address; and (2) a twelve-month account history for your mortgage loan. Other Information you should know: The information you put on the Mediation Information Form and the paperwork you send with it will be treated as confidential and will not be shared without your consent with anyone besides your lender, its attorneys, and a court-employed mediator with the Foreclosure Mediation Program. You may be asked to give additional information as part of the mediation process. If you need help filling out the Mediation Information Form, or advice about the workouts available to you, or help preparing for the Foreclosure Mediation Program, you may contact one of the agencies contained on the attached Notice of Community-Based Resources(JD-CV-126) You may also get help filling out this form at any Court Service Center located in most Judicial District courthouses. However, if you are not able to get help with filling out this form quickly enough in order to send it to the plaintiff's attorney on time, you still must follow instructions 1 and 2 above, under “What you must do”. American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 3 Loan Number: Personal Information: Borrower (First and last name) Co-Borrower (First and last name) Property address Contact number (Telephone/cell) Number of people in household Mailing address (If different from property address) Mortgage lender/servicer Monthly income Borrower Co-borrower Gross (Before deductions) 1. Monthly income (Wage/salary) Net (After deductions) Gross Net $ $ $ $ 2. Self employment 3. Social Security/Social Security disability 4. Pension/retirement 5. Alimony/child support received (Optional - you do not have to give this information) 6. Income from renters 7. Contribution from non-borrowers living in the home 8. Unemployment/food stamps 9. Other 10. Total income Monthly living expenses - do not include expenses deducted from your paystub Alimony/child support paid $ Life/disability insurance Auto gas/repair Memberships/union dues Auto insurance Minimum credit card payments Auto taxes Personal loan payments Cable/satellite TV & phone Pet expenses Internet service Prescriptions Child care Property services Children's activities Security services Clothing/dry cleaning Subscriptions Co-pays Telephone (cell) Electric bill Trash disposal Food (in-home) $ Tuition/school supplies JD-CV-125 New 8-11 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Gas or oil bill Other (please specify) Health and dental insurance Other (please specify) Homeowners/condo association fees Other (please specify) Homeowners insurance Other (please specify) Household items Other (please specify) Secured debts - Loans (Monthly payments) First mortgage $ Car payment Second mortgage Student loans Property taxes Other (please specify) Car payment Other (please specify) Total monthly living expenses and secured debts (Add up all monthly living expenses and secured debts above) $ $ I am having difficulty making my monthly payment because (please check all that apply): My household income has been reduced. For example: unemployment, underemployment, reduced pay or hours, decline in business earnings, death, disability or divorce of a borrower or coworker. My monthly debt payments are excessive and I am overextended with my creditors. Debt includes credit cards, home equity or other debt. My expenses have increased. For example: monthly mortgage payment reset, high medical or health care costs, uninsured losses, increased utilities or property taxes. My cash reserves, including all liquid assets are insufficient to maintain my current mortgage payment and cover basic living expenses at the same time. Other: Documents that must be sent with this form: 1. Proof of income - Pay stubs for all jobs from all wage earners for the most recent month - Personal bank statements for the two most recent and consecutive months (all pages, including bank logo and your name) - Business bank statements for the two most recent and consecutive months (all pages, including bank logo and business name) - only if self-employed - Most recent award letter for any benefits (including disability income, Social Security, food stamps, pension, public assistance and adoption assistance) - Recent year-to-date Profit & Loss statement (signed and dated) - only if self-employed - Two years' most recent federal tax returns (with all schedules, signed and dated by all taxpayers on page 2) - For rental income, copies of all leases with signatures. If the rental income is for another property, also include the amount paid for the mortgage, taxes and insurance on the property - Contribution letters from all non-borrowers who live in the household and contribute along with proof of their income (signed and dated) - Copy of court order showing payments received for alimony or child support or both - only if alimony or child support or both is included in you income 2. Proof of Occupancy: - Most recent utility bill; preferably one of the following: gas, electric, or water 3. IRS Form 4506T-EZ (can be found at http://www.irs.gov/pub/irs-pdf/f4506t.pdf) All documents must include loan number at top of page and be dated within 60 days of the date submitted. Borrower: Co-Borrower: Signature Signature Print name Print name Date Date JD-CV-125 New 8-11 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com