PENNSYLVANIA HOUSING FINANCE AGENCY – HERO PREQUALIFICATION FOR ASSISTANCE FORM

The Pennsylvania Housing Finance Agency (PHFA) will use this Prequalification Form, the Required Documents listed below and
other financial information to help determine if, and to what extent, you are eligible for an assistance loan.
 If you do not submit all required documents and requested information, PHFA may not be able to help you.
 For assistance completing this form and gathering the required documents you may contact one of the mortgage
counseling agencies from the enclosed list of National Foreclosure Mitigation Counseling Agencies (NFMC) or you
may also call a PHFA HERO Loan Program Specialist at 1-800-822-1174.
MAIL THIS COMPLETED, SIGNED & DATED FORM ALONG WITH COPIES OF THE REQUIRED DOCUMENTS LISTED BELOW TO:
PA HOUSING FINANCE AGENCY  PO BOX 8029  HARRISBURG, PA 17105-8029 ATTENTION: HERO
REQUIRED DOCUMENTS
Attention: If you pay your taxes and insurance yourself provide required document #2, 3 and 4.
If you escrow for taxes and insurance with your Mortgage Company, provide required document #6.
1. Current homeowner’s insurance policy declaration page, and if applicable, your flood insurance policy declaration page.
2. Billing documentation showing the terms of payment and the date your insurance policy(s) is paid through.
3. THIS YEARS real estate tax bills for School, City/Local and/or County. If taxes are paid, provide paid receipts from your tax
collector or other proof of payment.
4. If PREVIOUS YEARS real estate tax bills for School, City/Local and/or County are unpaid provide a “Tax Certification” from the
Tax Claim Bureau. ***Speak to your local tax collector to obtain the Tax Claim Bureau contact information for your property***
5. Include the dollar amount of all unpaid real estate taxes on page 3 of this Assistance form.
6. Escrow Analysis Statement and/or your Year End Mortgage Statement from your Mortgage Company.
7. Adjustable Rate Mortgage (ARM) interest rate change notice – provide if you have an Adjustable Rate Mortgage.
8. Most recent billing statement from your mortgage company. If your monthly billing statement does not show the outstanding
balance owed or arrearages due, ask your mortgage company to provide you this information in writing.
9. Current bank statements for all assets accounts (checking, savings, etc.) for all applicants.
10. Three recent pay stubs for all employed applicants who will be signing the loan documents.
11. Award letter for social security, pension, disability OR bank statement showing deposit of these or other sources of income.
12. If applicable; provide a 12 month payment history from Domestic Relations for child support.
13. Year-to-Date un-audited Profit and Loss Statement (if self-employed); signed and dated by you.
14. Two most recent years filed Federal Income Tax Returns, complete with all schedules and W-2 Forms.
15. Copy of all outstanding legal document(s) for the property: Note(s); Mortgage(s); Mortgage Rider(s); and Deed.
16. Property Appraisal. If you don’t have a copy, your mortgage company should provide you with one.
APPLICANT INFORMATION
Only the income of the borrower(s) on the current Note will be used for income limits and for qualifying purposes
Applicant: Social Security #:
Marital Status: Married Separated Unmarried Divorced Widow/Widower Number of Dependents: Ages:
Co-Applicant: Social Security #:
Marital Status: Married Separated Unmarried Divorced Widow/Widower Number of Dependents: Ages:
Relationship to Applicant: County:
Property Address: City: State: Zip Code:
Mailing Address: City: State: Zip Code
Dwelling: Single Double Row Condo/PUD Mobile/Trailer Multiple Units (Please explain)
Number of occupants residing in the property: _________ Do you currently live in the mortgaged property? Yes No
How long have you lived in the mortgaged property? Yrs Is this your primary residence? Yes No
Do you own the mortgaged property? Yes No
Are all owners a part of prequalification and willing to sign loan documents if approved? Yes No
If no, explain:
Is the property used for any type of business? Yes No If yes, what percent? Explain:
Please use the space provided on page 4 of this form to explain any “Yes” answer Applicant Co-Applicant
1) Are there any outstanding liens or judgments against you? Yes No Yes No
2) Have you now or in the past 7 years filed Chapter 13 or Chapter 7 bankruptcy? Docket #: Yes No Yes No
3) Have you now or in the past 7 years had property foreclosed on or given title or deed in lieu thereof Yes No Yes No
4) Are you a party to a lawsuit? Yes No Yes No
Note: Completing this form and providing PHFA with the required documents, will not stop any foreclosure action your
current mortgage company may have started or relieve you of your responsibility to your current mortgage company.
Note: If you are currently in a bankruptcy, you may need to obtain court approval to proceed with your HERO loan
request. You should consult with your bankruptcy attorney.

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 MONTHLY INCOME: EARNED INCOME
List employment data for all applicants who will sign loan documents if approved for an assistance loan. When calculating Gross and Net
pay per month list any overtime or bonus pay received separately from your base pay. (Attach separate sheet if necessary.)
List each person who is named on your present mortgage documents and provide requested information.
Net Pay
Present & Previous Reason Gross Per
Applicant/ Co- Dates of
Employers & Addresses for Position for Pay Per Month
Applicant Name Employment
last 2 years Leaving Month (Gross minus
taxes)

MONTHLY INCOME: EARNED INCOME

List all other sources of Income such as social security, pensions, unemployment/workers compensation, cash assistance, children,
boarder, child support, alimony, etc.
Enter monthly amount of End Date
Source of Other Income Start Date
income (if applicable)
Child Support Monthly amount: $
Disability Monthly amount: $
Public Assistance Monthly amount: $
Pension Monthly amount: $
Social Security Monthly amount: $
Supplemental Social Security Monthly amount: $
Unemployment Monthly amount: $
Workers Compensation benefits Monthly amount: $
Food Stamps Monthly amount: $
Alimony Monthly amount: $
Do you collect rental income? Monthly amount: $
Other Monthly amount: $
MONTHLY INCOME: SOURCES OF FUTURE INCOME
List all future income expected from insurance/disability claims, lawsuits, alimony, child support, social security, workers comp. etc.

Source of future Income Enter monthly amount of income Start Date

Insurance claims Monthly amount: $

Disability claims Monthly amount: $
Lawsuits Monthly amount: $
Alimony Monthly amount: $
Child Support Monthly amount: $
Other Monthly amount: $
ASSETS
Asset Account Balance or Value
Cash on hand $
Checking account: Bank Name & Account # $
Savings account: Bank Name & Account # $
Savings bond $
Life insurance (cash value) $
401 (K) account or Other Retirement fund (Type/Value) $
Real Estate: Value of current home $
Other Real Estate: Address/Value $
Automobiles: Make(s) & Year(s) $
Other Assets (Itemize). (Attach separate sheet if necessary.) $

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 MONTHLY LIVING EXPENSES
(List "normal" monthly payments. Do not list any expenses that are payroll deducted.)
Expenses Monthly Payment Expenses Monthly Payment
Automobile insurance $ Dry Cleaning $
Gasoline $ Toiletries $
Automobile expenses $ Pet Food $
Education, tuition, books $ Pet Care $
Electricity $ Pension / IRA / 401K cont. $
Gas to Heat Home $ Tobacco / Alcohol $
Oil to Heat Home $ Hair Cuts $
Water / Sewer $ Union Dues $
Trash removal $ Entertainment $
Home Telephone $ Clubs / Magazines / Gifts $
Cell Telephone $ Day Care $
Internet Service $ Alimony $
Cable / Dish / TV Service $ Child Support $
Prescription $ Groceries / Food $
Medical Supplies $ Lunches $
Medical Bills / Co-pays (not paid by
insurance $ Clothing $
Credit Life Insurance (List
Life Insurance $ only if not escrowed) $
Medical / Dental Insurance $ House Maintenance $
Per Capita / Personal
Church / Donations $ Prop. Taxes $
Condo Fees / Association
Bus / Public Transportation $ Dues
Parking / Tolls $ Real Estate Taxes (List
Other $ only if not escrowed) $
Other $ Hazard Insurance (List
Other $ only if not escrowed) $

Mortgage(s)
Address / Phone # Loan Loan Term &
Mortgagee / Holder Loan Type
(indicate if servicer) Number Amount Rate
1. $
2. $
3. $
Last Pmt. Applied to Total Amount
Monthly Payment Date of Last Full Payment
Month/Year Delinquent
1. $ $
2. $ $
3. $ $

Automobile Loan(s), Installment Loan(s), Credit Card Debt(s), Taxes and/or Condo/PUD Fees Due and Unpaid, Other
Date of No. of
Present Monthly Date
To Whom Paid Type of Debt Last Payments
Balance Payment Opened
Payment Past Due

$ $
$ $
$ $
$ $
$ $
$ $
$ $

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 *** ATTACH ADDITIONAL PAGES IF NECESSARY TO ANSWER ANY QUESTIONS ON THIS FORM***
GENERAL INFORMATION
Circumstances: Explain why you are applying for a HERO assistance loan. What caused you to get behind in your mortgage
payments? Be specific with dates and events. List any major house repairs: heat, plumbing, electrical, roof, etc.

Explain how you have managed your money if your mortgage company no longer accepts payments. Provide bank
statements to show a savings pattern or paid receipts to show how you spent the money.

Explain why you answered “Yes” to any of the questions on page 1 of this form.
Provide Bankruptcy Petition # (Docket #); filing date(s); discharged or dismissed date(s), if applicable; and the name and
telephone # of your Bankruptcy Attorney.

INFORMATION FOR GOVERNMENT MONITORING PURPOSES

The following information is requested by the Federal Government for certain types of loans related to a dwelling in order to monitor the lender’s
compliance with equal credit opportunity, fair housing, and home mortgage disclosure laws. You are not required to furnish this information, but
are encouraged to do so. The law provides that a lender may not discriminate either on the basis of this information, or on whether you choose
to furnish it. If you furnish the information, please provide both ethnicity and race. For race, you may check more than one designation. If you
do not furnish ethnicity, race, or sex, under Federal regulations, this lender is required to note the information on the basis of visual observation
and surname if you have made this application in person. If you do not wish to furnish the information, please check the box below. (Lender
must receive the above material to assure that the disclosures satisfy all requirements to which the lender is subject under applicable state law
for the particular type of loan applied for.)
APPLICANT CO-APPLICANT
I do not wish to furnish this information. I do not wish to furnish this information.
Ethnicity: Hispanic or Latino Not Hispanic or Latino Ethnicity: Hispanic or Latino Not Hispanic or Latino
Race: American Indian or Alaska Native Asian Race: American Indian or Alaska Native Asian
Native Hawaiian or Other Pacific Islander Native Hawaiian or Other Pacific Islander
White Black or African American White Black or African American
Sex: Female Male Sex: Female Male

AGREEMENT: The undersigned is applying for an assistance loan to be secured by a mortgage or deed of trust on the property described herein, and represents
that the property will not be used for any illegal or restricted purpose and that all statements made in this application are true and are made for the purpose of
obtaining a loan. Verification may be obtained from any source named in this application. The undersigned hereby consents to the acquisition of all pertinent data
necessary by the Pennsylvania Housing Finance Agency in order to evaluate eligibility, including, but not limited to, personal Income Tax returns, employment
verification, as well as deposit and appraisal information, and my/our social security number to obtain a credit report.
MISREPRESENTATION: I/we fully understand that any intentional misrepresentation of any financial information in conjunction with the filing of this application
will result in the assistance loan being denied or immediate repayment required for all loan disbursements made as a result of such misrepresentations.

_____________________________________________ _______________ _______________________________________________ ______________

Applicant’s Signature Date Co-Applicant’s Signature Date
Hours can be reached: Hours can be reached:
Home Phone (____)______________________ __________________ Home Phone (____)______________________ __________________
Work Phone (____)______________________ __________________ Work Phone (____)______________________ __________________
Cell Phone (____)______________________ _________________ Cell Phone (____)______________________ __________________
E-mail Address (if applicable) _____________________________________ E-mail Address (if applicable) _____________________________________

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 AUTHORIZATION FOR RELEASE OF INFORMATION

I am applying to the Pennsylvania Housing Finance Agency (“PHFA”) for the Homeowners’ Equity
Recovery Opportunity (HERO) program. I understand that PHFA, its employees and agents, and/or the
below named PHFA Approved Counseling Agency (“Counseling Agency”) will be checking my credit history,
mortgage payment history, mortgage delinquency information, employment history and other personal and
financial information in order to determine my eligibility for a HERO loan.

I hereby authorize PHFA and/or the below named Counseling Agency to check my credit history,
mortgage payment history, mortgage delinquency information, employment records, and other personal and
financial information. This shall include my Federal and State tax returns for the previous three years.

I hereby authorize my mortgage lender(s), mortgage servicer(s), employer(s), or any other private
company, for-profit or non-profit organization and government agency or any other person or entity to
discuss and disclose such information to PHFA and/or the below named Counseling Agency.

I authorize the release of the above-mentioned information by any means possible, including but not
limited to phone discussions, mail, facsimile, e-mail or any other electronic means. Information in writing
should be sent to the Pennsylvania Housing Finance Agency, Homeownership Programs, P.O. Box 8029,
Harrisburg, PA 17105-8029.

_____________________________________ _______________________
Print and Sign Name Date

_____________________________________ _______________________
Print and Sign Name Date

Witness: _______________________________ Date: ________________

_______________________________________
PHFA Approved Counseling Agency (if applicable)

NOTE: Authorization form active one year from applicant(s) signature date.

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