UNITED STATES BANKRUPTCY COURT SOUTHERN DISTRICT OF NEW YORK ----------------------------------------------------------x In re: Chapter Case No. - ( ) Debtor(s). ---------------------------------------------------------x LOSS MITIGATION REQUEST ­ BY THE DEBTOR I am a Debtor1 in this case. I hereby request Loss Mitigation with respect to: [Identify the Property, last four (4) digits of Loan account number and Creditor(s) for which you are requesting Loss Mitigation] SIGNATURE I have reviewed the Loss Mitigation Program Procedures, and I understand that if the Court orders Loss Mitigation in this case, I will be bound by the Loss Mitigation Program Procedures. I agree to comply with the Loss Mitigation Program Procedures, and I will participate in Loss Mitigation 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 this Loss Mitigation. 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. The Debtor hereby permits the Creditor listed above to contact (check all that apply): The Debtor directly. Debtor's bankruptcy counsel. Other: Sign: Print Name: Telephone Number: E-mail address (if any): Date: . , 20 1 Unless otherwise provided herein, all capitalized terms are defined in the Southern District of New York's Loss Mitigation Program Procedures. The Loss Mitigation Program Procedures' definition of "Debtor" includes joint debtors. Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com