FORECLOSURE MEDIATION FINANCIAL WORKSHEET COUNTY Plaintiff's Name Borrower's Name Social Security Number Date of Birth (mm/dd/yyyy) DOCKET NO: F First Defendant's Name ­ v. PERSONAL INFORMATION Co-Borrower's Name Social Security Number Date of Birth (mm/dd/yyyy) Married Civil Union/ Domestic Partner Separated Unmarried (single, divorced, widowed) Dependents (Not listed by Co-Borrower) Present Address (Street, City, State, Zip) Married Civil Union/ Domestic Partner Separated Unmarried (single, divorced, widowed) Dependents (Not listed by Borrower) Present Address (Street, City, State, Zip) EMPLOYMENT INFORMATION Employer Position/Title Second Employer Position/Title Date of Employment Self Employed Date of Employment Employer Position/Title Second Employer Position/Title Date of Employment Self Employed Date of Employment ASSETS Assets: Liquid Estimated Value Amt. Owed Net Value Cash Savings Accounts Checking Accounts Certificates of Deposits (CD's) Stocks/Bonds/Mutual Funds All Retirement Assets (401(k)s, IRA's, etc.) Assets: Non-Liquid Primary Home Other Real Estate Personal Property Automobile 1 Automobile 2 Cash Value of Life Insurance Other Assets (Limited Partnership, etc.) Total MONTHLY INCOME Monthly Income: Borrower Co-Borrower Total Gross Salary/Wages Net Salary/Wages Overtime Wages Commissions Bonuses Social Security Unemployment Income Disability (short term or long term) Rental Income Child Support/Alimony Pension Other Contributory Income Total Net (do not include Gross income) Revised: 10/2012, CN 11269-English, (Foreclosure Mediation Financial Worksheet) American LegalNet, Inc. www.FormsWorkFlow.com page 1 of 2 EXPENSE AND LIABILITIES Monthly Payments Balance Due # Mos. Delinquent First Mortgage (plus real estate taxes) Second Mortgage Other Judgments Homeowners' Association Dues Property Maintenance Other Mortgages Automobile Loan(s) Automobile Insurance Auto Expenses (gas, maintenance, etc.) Student Loans (tuition, private school ) Child Support/Child Care Dependent Care Alimony Medical Charges/Prescriptions Utilities: Gas Utilities: Electricity Utilities: Water/Trash/Sewer Home Telephone/Cell Phone Cable TV/Internet Groceries/Toiletries Health Insurance (health, dental, etc., not deducted from checks) Leisure (hobbies, dining out, movies, etc.) Contributions/Gifts (church donations, birthday gifts, etc.) Newspapers/Periodicals Additional Expenses: Credit Cards: (add separate sheet for additional lines) Credit Cards/Installment Loan Credit Cards/Installment Loan Credit Cards/Installment Loan Credit Cards/Installment Loan Credit Cards/Installment Loan Total I / We obtained a mortgage loan(s) secured by the above-described property. I / We have described my/our present financial condition and reason for default and have attached required documentation. I / We consent to the release of this financial worksheet and attachments to the mediator and the plaintiff or plaintiff's servicing company by way of the plaintiff's attorney. By signing below, I / we certify the information provided is true and correct to the best of my / our knowledge. Signature of Borrower Home Phone No. Cell Phone No. Date Signature of Co-Borrower Home Phone No. Cell Phone No. Date Revised 10/2012, CN 11269-English, (Foreclosure Mediation Financial Worksheet) American LegalNet, Inc. www.FormsWorkFlow.com page 2 of 2