Your Age: 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 Marital Status: Married Divorced Single Do You Own Your Residence? Select Yes No In Indiana, unemployed individuals may be eligible for a mortgage payment reduction. To speak with a counselor about your payment reduction options, provide the following information:.   Property Type : Single Family Home Condominium Townhouse Multi-Family Single Wide Manufacture Home Double Wide Manufacture Home Property Value : $90,001 - $100,000 $100,001 - $110,000 $110,001 - $120,000 $120,001 - $130,000 $130,001 - $140,000 $140,001 - $150,000 $150,001 - $160,000 $160,001 - $170,000 $170,001 - $180,000 $180,001 - $190,000 $190,001 - $200,000 $200,001 - $225,000 $225,001 - $250,000 $250,001 - $275,000 $275,001 - $300,000 $300,001 - $325,000 $325,001 - $350,000 $350,001 - $375,000 $375,001 - $400,000 $400,001 - $425,000 $425,001 - $450,000 $450,001 - $475,000 $475,001 - $500,000 $500,001 - $550,000 $550,001 - $600,000 $600,001 - $650,000 $650,001 - $700,000 $700,001 - $750,000 $750,001 - $800,000 $800,001 - $850,000 $850,001 - $900,000 $900,001 - $950,000 $950,001 - $1,000,000 Over $1,000,000 Mortgage Balance : $100,001 - $110,000 $110,001 - $120,000 $120,001 - $130,000 $130,001 - $140,000 $140,001 - $150,000 $150,001 - $160,000 $160,001 - $170,000 $170,001 - $180,000 $180,001 - $190,000 $190,001 - $200,000 $200,001 - $225,000 $225,001 - $250,000 $250,001 - $275,000 $275,001 - $300,000 $300,001 - $325,000 $325,001 - $350,000 $350,001 - $375,000 $375,001 - $400,000 $400,001 - $425,000 $425,001 - $450,000 $450,001 - $475,000 $475,001 - $500,000 $500,001 - $550,000 $550,001 - $600,000 $600,001 - $650,000 $650,001 - $700,000 $700,001 - $750,000 $750,001 - $800,000 $800,001 - $850,000 $850,001 - $900,000 $900,001 - $950,000 $950,001 - $1,000,000 Loan Type : Purchase Refinance Home Equity VA - Finance FHA - Finance Second Mortgage Loan Amount : $100,001 - $110,000 $110,001 - $120,000 $120,001 - $130,000 $130,001 - $140,000 $140,001 - $150,000 $150,001 - $160,000 $160,001 - $170,000 $170,001 - $180,000 $180,001 - $190,000 $190,001 - $200,000 $200,001 - $225,000 $225,001 - $250,000 $250,001 - $275,000 $275,001 - $300,000 $300,001 - $325,000 $325,001 - $350,000 $350,001 - $375,000 $375,001 - $400,000 $400,001 - $425,000 $425,001 - $450,000 $450,001 - $475,000 $475,001 - $500,000 $500,001 - $550,000 $550,001 - $600,000 $600,001 - $650,000 $650,001 - $700,000 $700,001 - $750,000 $750,001 - $800,000 $800,001 - $850,000 $850,001 - $900,000 $900,001 - $950,000 $950,001 - $1,000,000 Mortgage Payment (Monthly) : Please Select $0 - $1,000 $1,000 - $1,500 $1,500 - $2,000 $2,000 - $2,500 $2,500 - $3,000 $3,000 - $3,500 $3,500 - $4,000 $4,000 - $4,500 $4,500 - $5,000 $5,000 - $5,500 $5,500 - $6,000 $6,000 - $6,500 $6,500 - $7,000 $7,000 - $7,500 $7,500 - $8,000 $8,000 - $8,500 $8,500 - $9,000 $9,000 - $9,500 $9,500 - $10,000 $10,000+ Behind on payments? : Select I'm Not Behind 1 Month 2 Months 3 Months 4+ Months Mortgage Rate : Under 2% 2.00% - 2.49% 2.50% - 2.99% 3.00% - 3.49% 3.50% - 3.99% 4.00% - 4.49% 4.50% - 4.99% 5.00% - 5.49% 5.50% - 5.99% 6.00% - 6.49% 6.50% - 6.99% 7.00% - 7.49% 7.50% - 7.99% 8.00% - 8.49% 8.50% - 8.99% 9.00% - 9.49% 9.50% - 9.99% 10.00% - 10.49% 10.50% - 10.99% 11% or higher Mortgage Rate Type : Select Unknown Fixed Adjustable   *In Indiana, unemployed residents may be eligible for debt relief benefits (temporary deferred payments) during their period of unemployment. Do you currently have outstanding debt? -Select- Yes No *State your approximate amount of outstanding credit card debt (Student Loans Do Not Apply):    Select... $10,000 - $14,999 $15,000 - $19,999 $20,000 - $34,999 $35,000 - $49,999 Above $50,000 *It is recommended that you become informed of the training/education benefits that are available in Indiana during your period of unemployment. Choose one carreer/occupational training field: - Choose One - Business & Administration Arts and Design Communication Studies Computers and Technology Criminal Justice and Legal Education Health and Wellness Hospitality and Tourism Liberal Arts Medical and Nursing Public Administration Science, Math & Engineering Social Science Trade and Vocational No Thanks, No Degree   State the highest level of education you have obtained: - Choose One - High School GED HS Diploma Some College Associates Degree Bachelors Degree Master's Degree Master of Advanced Studies Doctorate I Have Registered With a Local Indiana Workforce Job Resource Center: Yes No

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