UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF NEW YORK ------------------------------------------------------X In Re: Chapter Case No. Debtor(s) ------------------------------------------------------X LOSS MITIGATION REQUEST - BY A CREDITOR I am a Creditor (including a holder, servicer or trustee of a mortgage or lien secured by property used by the Debtor as a principal residence) of the Debtor in this case. I hereby request to enter into the Loss Mitigation Program with respect to [Identify the property, loan and creditor(s) for which you are requesting loss mitigation]: _________________________________________________________________________ [Identify the Property] _________________________________________________________________________ [Loan Number] _________________________________________________________________________ [Creditor’s Name and Address] SIGNATURE I understand that if the Court orders loss mitigation in this case, I will be expected to comply with the Loss Mitigation Procedures. I agree to comply with the Loss Mitigation Procedures, and I will participate in the Loss Mitigation Program in good faith. I understand that loss mitigation is voluntary for all parties, and that I am not required to enter into any agreement or settlement with any other party as part of entry into the Loss Mitigation Program. I also understand that no other party is required to enter into any agreement or settlement with me. I understand that I am not required to request dismissal of this case as part of any resolution or settlement that is offered or agreed to during the Loss Mitigation Period. Sign: _____________________________ Date: _______________________, 20______ Print Name: ______________________________________________________________ [First and Last Name] Telephone Number: ________________________________________________________ [i.e. 999-999-9999] E-mail Address [if any]: ____________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com