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This difficulty or situation happened on or about this date MM/DD/YYYY.

I/We believe that my/our situation is (circle one) Temporary / Permanent

The following is a brief account of my/our situation: (explain your situation and tell them why you feel you can now afford your new payments/payments)

I/We, (your name), state the information provided above to be true and correct to the best of my/our knowledge.
Borrower’s Signature

Date

Co-Borrower’s Signature

Date  

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