State of North Carolina Agreement Signature

State Home Foreclosure Prevention Project

Loan Servicer: {HO_A}
Loan Number: {135}
Borrower Name:                                        Co‑Borrower Name:
Property Address:

 I/we, , the undersigned Borrower do hereby authorize servicer to release any and all information about any and all of my account(s) to any representative of the North Carolina Housing Finance Agency and
Name of Third Party Authorized Agency:   Alliance Credit Counseling (Charlotte-based)
Agency Address:                                        8000 Corporate Center Drive, Suite 114
                                                                   Charlotte, NC 28226
Telephone Number:                                    (704) 943-0387
Relationship to Borrower:                           Housing Counseling Agency

and its representatives. I understand that this information is needed so that I can receive counseling assistance.  The information released by servicer may include, but is not limited to, information relating to my loan amount and payment transactions and/or provision of copies of any and all loan documents and communication history associated with my account(s) in the possession of servicerUnder no circumstances will I hold servicer responsible for any claims, liabilities or damages that may arise as a result of or in connection with servicer’s provision of information pursuant to the terms of this Agreement.

I/We further authorize servicer to speak with any representative of the North Carolina Housing Finance Agency and any third party authorized agency indicated herein and its representatives regarding all aspects of my account(s) and account history, including information provided by any prior servicer.

I/We also authorize servicer to notify the North Carolina Housing Finance Agency and any third party authorized agency indicated herein in the event that my/our loan payments become delinquent in the future, or if a loss mitigation workout is discussed, implemented, completed and/or results in default.  The North Carolina Housing Finance Agency and any third party authorized agency indicated herein agrees to maintain the confidentiality of borrower(s) information in accordance with NCGS § 45‑106.

I acknowledge that this authorization will remain in effect for the duration of time that servicer serves as the loan servicer for my account(s). I also acknowledge that should I wish to terminate this authorization, I will notify servicer in writing. This authorization will not be valid unless signed below by
borrower and all co‑borrowers named above.

Primary Borrower (Print Name): _______________________
Last4 Digits of Social Security Number:  

Signature:________________________________________          Date:  _________________

Co‑Borrower (Print Name): ____________________________
Last4 Digits of Social Security Number:  

Signature: ________________________________________          Date:__________________

The State Home Foreclosure Prevention Project was created by the North Carolina General Assembly.
North CarolinaHousing Finance Agency • 3508 Bush Street • Raleigh, NC • 888-442-8188 •

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