Confidential Client Information Form

If you would like Reinstatement Services, Inc. to contact you via e-mail regarding your best plan alternative, please fill in the following form. Information will be sent to the e-Mail address supplied within one business day.

In accordance with our policies and procedures, the contact information that you provide on this form will be kept in the most confidential manner and will not be shared with anyone without your expressed, written permission.

Please provide the following information: First Name MI Last Name e-Mail Address Phone Number format: xxx-xxx-xxxx Dollar Amount Past Due Number of Months Delinquent 1 month 2 months 3 months 4 months 5 months 6 to 9 months 10 to 12 months More than 1 year Have You Filed Bankruptcy Within the Past 12 Months? Yes No Has a Sale Date Been Established? Yes. If so, when is the Sale Date? format: mm/dd/yyyy No Do You Have a Current or Past Forbearance Arrangement with Your Lender? Current Past None Lender Information: You may be entitled to receive a discounted rate for our service if your lender is an affiliate member. Please provide the following information for us to determine eligibility. Lender Name Lender Address Address: City: State: Select Your State Alabama, AL Alaska, AK Arizona, AZ Arkansas, AR California, CA Colorado, CO Connecticut, CT Delaware, DE Florida, FL Georgia, GA Hawaii, HI Idaho, ID Illinois, IL Indiana, IN Iowa, IA Kansas, KS Kentucky, KY Louisiana, LA Maine, ME Maryland, MD Massachusetts, MA Michigan, MI Minnesota, MN Mississippi, MS Missouri, MO Montana, MT Nebraska, NE Nevada, NV New Hampshire, NH New Jersey, NJ New Mexico, NM New York, NY North Carolina, NC North Dakota, ND Ohio, OH Oklahoma, OK Oregon, OR Pennsylvania, PA Rhode Island, RI South Carolina, SC South Dakota, SD Tennessee, TN Texas, TX Utah, UT Vermont, VT Virginia, VA Washington, WA West Virginia, WV Wisconsin, WI Wyoming, WY Zip Code: Lender Phone Number xxx-xxx-xxxx Extension How did You Hear About RSI? Select One Internet Search Engine Referral Radio Advertisment TV Advertisement Newspaper Magazine Billboard Advertisement Additional Information