Forbearance Application

PRELIMINARY COVID-19 FORBEARANCE COUNSELING APPLICATION

CONTACT INFORMATION

Homeowner Name:

Co-Homeowner Name (if applicable):

Property Address:

City/State/Zip Code:

Is this your Primary Residence?

Daytime Phone Number:

Is this:

E-Mail Address:

HOUSEHOLD SIZE AND INCOME CERTIFICATION

NUMBER OF ADULTS RESIDING IN THE HOUSEHOLD:

NUMBER OF CHILDREN RESIDING IN THE HOUSEHOLD:

NUMBER OF ADULTS AND/OR CHILDREN WHO RECEIVE INCOME (from any source):

Total household income (from all household members and all income sources):

Does your total household income exceed the limits listed below?

 

1 Person

2 People

3 People

4 People

5 People

6 People

7 People

8 People

50%

$20,600

$23,550

$26,500

$29,400

$31,800

$34,150

$36,500

$38,850

80%

$32,950

$37,650

$42,350

$47,050

$50,850

$54,600

$58,350

$62,150

120%

$49,440

$56,520

$63,600

$70,560

$76,320

$81,960

$87,600

$93,240

140%

$57,680

$65,940

$74,200

$82,320

$89,040

$95,620

$102,200

$108,780

MORTGAGE INFORMATION

Bank/Mortgage Company Name:

Current Balance:

Monthly Payment:

Estimated amount you currently have in Savings/Checking Accounts:

Is your Mortgage:

If your mortgage is delinquent, how many months?

Reason you are seeking a Forbearance:

If the reason above is "Other", please specify the reason here:

Did the reason listed above occur as a direct result of the Covid 19 Emergency?  Yes No

CERTIFICATION AND AUTHORIZATION TO RELEASE INFORMATION

  1. I/We certify that the application information provided in this application (most notably information regarding household size and income) is true and correct to the best of my/our knowledge.
  2. I/We authorize Keystone Challenge Fund to provide Polk County, City of Lakeland, City of Winter Haven or any other State/Federal Funding Source with information contained in this Application (if necessary for funding purposes).
  3. I/We am/are aware that this information is subject to Florida’s Sunshine laws.
  4. A photographic or carbon copy of this authorization may be deemed the equivalent of the original and may be used as a duplicate original.

Please type your name below as an electronic signature.

Electronic Signature of Homeowner:

Electronic Signature of Co-Homeowner or Spouse (if applicable):

FORBEARANCE COUNSELING AVAILABLE FOR POLK COUNTY RESIDENTS BEGINNING MAY 4TH
DUE TO COVID-19, ALL CLASSES FOR MAY, JUNE, AND JULY HAVE BEEN CANCELED
+