UNITED STATES BANKRUPTCY COURT SOUTHERN 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 loss mitigation with respect to: [Identify the property, loan and creditor(s) for which you are requesting loss mitigation] SIGNATURE I have reviewed the Loss Mitigation Procedures, and I understand that if the Court orders loss mitigation in this case, I will be bound by the Loss Mitigation Procedures. I agree to comply with the Loss Mitigation Procedures, and I will participate in loss mitigation in good faith. If loss mitigation is ordered, I agree to provide the Court with a written or verbal status report stating whether or not the parties particiaptee in one or more loss mitigation sessions, whether or not a settlement was reached, and whether negotiations are ongoing. I agree that I will not require the Debtor to request or cause 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: _____________________________ Title: _____________________________ Firm or Company: _____________________________ Telephone Number: _____________________________ E-mail address (if any): _____________________________ American LegalNet, Inc. www.FormsWorkflow.com