Triage Form

Date of Application:

Person Completing Form:

Working with any other foreclosure counseling organization

Yes No

Name of Organization:

Preferred Language?

English Spanish

Homeowner Information

Home Phone

Cell Phone

Other Phone

Email

Commitment

Want to stay in Home?

Yes No

Monthly Income (Gross)

Previous Delinquencies?

Yes No

When?

Previous Workouts?

Yes No

When?

Talked to Mortgage Company?

Yes No

Outcome:

Money Available?

Affordability

First Mortgage Payment

PITI?

Yes No

Mortgage Company:

Delinquent:

Yes No

Second Mortgage Payment

Mortgage Company:

Delinquent:

Yes No

Months Delinquent:

Third Mortgage Payment

Mortgage Company:

Delinquent:

Yes No

Months Delinquent:

Delinquent

Notices from attorney or court? Type:

Mediation scheduled? Date:

Reason for Default?

Response date:

Foreclosure sale scheduled? Date:

RFD Resolved?

Yes No

Current

Anticipated Date of Delinquency:

Reason payment is or will be unaffordable?

Interest Rate Reset Unemployment Reduced Income Other

If other, please describe:

Action Taken: FOR COUNSELOR USE ONLY

Triage Outcomes

Level

1: Referral info 2: Appt Immediately 3: Appt Soon 4: Appt Default 5: Appt Current 6: Transition

Provided or Sent Referral Info Sent Intake Packet Sent Workshop Schedule Registered for Workshop Scheduled Fl Appt Sent Transition Packet Scheduled Transition Appt Other

If other, please describe

Contact Us

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Office Phone

217-423-0352

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Housing Counselor

217-423-4901

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Mail To

P.O. Box 228, Decatur, IL 62525

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