WILL COUNTY CIRCUIT COURT FORECLOSURE MEDIATION PROGRAM INITIAL QUESTIONNAIRE FORM You have been named as a party in a foreclosure case. This case may result in the loss of your home. Court sponsored mediation may be available in your case. Mediation is a free, confidential, and voluntary process through which you and the lender that is seeking the foreclosure of your home may discuss ways to resolve this case including reinstatement of the loan and re-negotiation of the loan terms. THIS IS NOT AN EVICTION. La version en Espa�ol de esta forma; cuestionario inicial, esta' disponible en la pagina web: www.willcountycourts.com, o en el departamamento de la Secretaria del Circuito Tribunal del Condado de Will, 14 W. Jefferson Street, Joliet, Illinois 60432. Usted ha sido nombrado(a) como parte de una ejecuci�n hipotecaria. Este caso puede resultar en la p�rdida de su propiedad. ESTO NO ES UN DESALOJO. Please fill in the information on this form and bring it with you to the Foreclosure Mediation Pre-screening meeting. The date and location of that meeting is contained in the Summons you received with your complaint. The information provided will be used by the Court Mediator to make an initial determination if this case is suitable for mediation. This information will not be shared with anyone, unless you agree and then only with a representative of your mortgage lender. Name: _______________________________________________________ Case Number: ________________________________________________ Address: _____________________________________________________ Daytime Phone: _______________________________________________ 1. What is the total amount of your scheduled monthly payment to your lender? 2. If your property tax and property insurance are not included to the payment to your lender, what is the amount of your monthly property taxes and property insurance? 3. How many payments have you missed? 4. What are your monthly expenses not including the above monthly payments to your lender and any payments for property taxes and insurance? (See reverse side) ANDREA LYNN CHASTEEN, CLERK OF THE CIRCUIT COURT OF WILL COUNTY American LegalNet, Inc. www.FormsWorkFlow.com 117 Revised (12/16) 5. What is your monthly income? 6. Do you have any money saved? No Yes If Yes, how much? 7. Do you own any other property? No Yes If Yes, What is the difference between the value of the property and any mortgage or lien on the property? 8. Check all items that have caused you to miss payments: Injury or Illness Adjustable Interest Rate/ Balloon Payment Loss of employment My expenses exceed my income Other: __________________________________________________________________________ 9. If you marked Injury or Illness in question 8, are you now well? No Yes No Yes 10. If you marked Loss of employment in question 8, have you found a new job? 11. Do you desire to keep the property that is subject of this case? No Yes 12. If your answer to question 11 was NO, would you consider the following (check all that may apply): Deeding the Property to Lender Selling the Property to Third Party Consenting to Foreclosure (No deficiency judgment) 13. Is there any information that would be helpful in determining whether your case would be suitable for mediation? If so, please describe: ________________________________________ (Property Owner's Signature) ________________________________________ (Co-Owner's Signature) I consent to disclose information to lender representative _________ _________ (Initials) ANDREA LYNN CHASTEEN, CLERK OF THE CIRCUIT COURT OF WILL COUNTY American LegalNet, Inc. www.FormsWorkFlow.com 117 Revised (12/16)