Lake County Common Pleas Court

Case Name: _______________________________________________

Case No. __________

Defendants/Borrowers Mediation Questionnaire for Foreclosure Cases ***CAUTION***

You have been served with a Foreclosure Complaint that could cause you to lose your property. You should consult with an attorney concerning your rights and responsibilities. To avoid having a default judgment taken against you, you MUST serve your written Answer or Motion for Extension of Time to Answer or Otherwise Plead upon the attorney for the Plaintiff (if the Plaintiff does not have an attorney, you must serve the Answer or Motion for Extension of Time to Answer or Otherwise Plead on the Plaintiff) AND file your written Answer or such Motion with the court. Refer to the Summons on Complaint for additional details. This Questionnaire, even though it is required to be filled out, is NOT an Answer or Motion for Extension of Time to Answer or any other pleading. You are strongly urged to seek legal counsel. You may also be eligible for the assistance of a volunteer lawyer to represent you in the mediation. To determine your eligibility for a volunteer lawyer, call the legal aid office phone number, (440) 352-6200. Your interests will be best protected if you seek counsel early. However, if you choose to proceed without an attorney, understand that you may seek legal advice at any time throughout this process, though the Mediator will not provide legal advice. If you are seeking mediation and would like the court to consider your request, you are required to complete this form and return it to the Lake County Court Mediation Department. Please note that providing false or incorrect information within this form, may constitute a violation of the good faith requirement associated with the mediation process and result in sanctions. This form should not be filed with the Clerks office. This form must be completed and returned to the Lake County Mediation Department, if you wish the court to fully consider your mediation application. Please return this document to the Lake County Mediation Department. Please note again that this form is not to be filed, rather it is to be returned to the Lake County Court Foreclosure Mediation Department, Magistrates Office, Second Floor, 47 N. Park Place, Painesville, Ohio 44077. Any questions or concerns may be directed to Mediator Adrienne Foster, at (440) 350-2053. You will receive written notice if the mediator determines your case will be mediated. If the case will continue on the trial docket, you will not receive written notice staying the case. When completing this form, the word you means any debtor on the loan. If you need additional space, attach a separate sheet. Should this case be approved for mediation, the order doing so shall operate as a stay of proceedings. The case will be de-activated until the conclusion of the mediation process, and no further discovery and preparation, motion practice, and the filing of responsive pleadings will occur during the mediation process, unless otherwise agreed upon by the parties and ordered by the court. Note that a mere request for mediation and submission of this form to the Mediation Department does not automatically operate as a stay of proceedings. Should mediation be deemed appropriate, the stay will be established via court order. Mediation is a free, voluntary process through which you, as the debtor, and the creditor can determine if an agreement can be reached to cure any defaults in the loan and re-negotiate the terms of the loan in a manner that could allow you to remain in your property or other terms as agreed by the parties. The court will provide a mediator who facilitates the mediation process. The mediator will not give legal advice to either party and you are therefore urged, but not required to retain an attorney to represent you and to provide you with legal advice. Please complete the entirety of the form and use just one form for all debtors on the loan. 1. YES NO Is this property your only residence?

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2. 3. 4. 5.

YES

NO

Are you currently living in this property? YES NO Are you interested in trying to remain in this property?

YES NO If you are not interested in trying to remain in this property, are you interested in discussing other options with your lender? YES NO Have you received counseling or assistance in this matter (foreclosure avoidance) from a community agency such as the Fair Housing Resource Center, Save the Dream or other such agency? If yes, you are strongly encouraged to contact said agency and request any relevant documentation or correspondence, so that you have it available at any potential mediation. Briefly detail any assistance you have received from a community agency: _____________________________

6. Spouse:

YES

NO

_______________________________________________________________________ __ _______________________________________________________________________ _ Are you and/or your spouse presently employed? If yes, how long have you and/or your spouse been employed by your current employer(s)? You: ____________ year(s), ____________ year(s) you filed for bankruptcy in the past? If yes, provide details:

7. YES NO Have ____________________

________________________________________________________________________ 8. 9. 10. ____ ___ 11. liens YES NO Do other mortgages or liens exist on this property? Examples of other mortgages and are second mortgages, home equity loans, tax liens, child support liens, judgments from lawsuits. List them below: Who is owed? How much is due?
Past due? (yes/no)

YES

NO

Are you in the process of filing/considering filing (circle one) bankruptcy? YES NO Answer? Have you filed an Answer or a Request for Extension of Time to

YES NO Have you received financial counseling? If yes, provide details: ______________________ _______________________________________________________________________ _______________________________________________________________________

_________________________

______________ ___________ _________________________ ______________ ______________ ___________ ______________

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_________________________ ______________ ___________ _________________________ ______________ ______________ ___________ _________________________ ______________ ______________ ___________ ______________ 12. Check all items that have made you miss your mortgage payments: _____ _____ _____ _____ _____ __ __ 13. 14. How many payments have you missed? _____ YES NO Have you signed any documents or agreements regarding your mortgage? If yes, please attach them. Documents/Agreement Attached: _______________________________________________________________________ YES NO Have you filed or do you plan to file a divorce or dissolution? Injury or illness; Adjustable Rate Mortgage (ARM): a mortgage loan where the interest rate changes periodically throughout the course of the loan; Balloon Payment: any repayment option under which the borrower is required to pay the entire amount of the outstanding balance of the loan as of a specified date or the end of a specified period; My expenses are more than my income; Other (please describe): _____________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

____ 15. 16.

YES NO Is or will this property be subject to an estate action in Probate Court? If yes, identify the jurisdiction, case name and number: ____________________________________________ _______________________________________________________________________ $__________ foreclosing? What is the amount of your monthly payment to the lender who is

____ 17. 18.

$__________ If your property tax and property insurance are not included in the payment to that lender, what is the amount of your monthly property taxes and insurance? $__________ What is your total monthly mortgage, property tax, and property insurance payment for this loan?

19.

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20. 21. 22. true.

$__________ What is your monthly net income (after income taxes and normal deductions) from all sources? $__________ What are your total monthly expenses without this mortgage, property tax, and property insurance (including payments on other property liens)? $__________ Total remaining net income (without this liens real estate expenses)

I state that I am of lawful age, that I have personal knowledge of the information noted above and that it is ___________________________________________ __________________________________________ _ Borrower/Homeowner (Please Sign) Email: ____________________________________

Borrower/Homeowner (Please Sign) Phone Number: _____________________________ Date: ______________________________________

I DO / DO NOT (circle one) approve that this form be sent to the lender and lenders attorney. If you are not represented by legal counsel it is recommended that you seek legal counsel before answering this question. Please note that your refusal to share this information may substantially hinder the ability to successfully mediate this matter and potentially reach a resolution that may allow you to remain in your home or provide other appropriate relief. ___________________________________________ Homeowner Signature If the borrower approved that this form be sent to the lender and lenders attorney, the borrower and/or borrowers counsel are encouraged to share this information with the lender and lenders attorney as soon as possible. The original must be returned to the Mediation Department, while a copy should be sent directly from you to the lender and lenders attorney. Be aware that if you have approved the sharing of this form with the lender and lenders attorney, the Mediation Department may opt to send this form to the lender and/or lenders attorney via mail, fax or e-mail, however, you bear the ultimate responsibility for exchanging this information with the lender and lenders counsel.

***DO NOT FILE THIS FORM WITH THE CLERK OF COURTS*** ***IF YOU ARE SEEKING MEDIATION, RETURN THIS FORM TO THE MEDIATION DEPARTMENT AND FORWARD COPIES TO THE PLAINTIFF AND PLAINTIFFS ATTORNEY***

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