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Loan Number:

Primary Borrower First Name:

Primary Borrower Last Name:

Email Address:

When you give us your mobile phone number, we have your permission to contact you at that number about all your Valley National Bank accounts. Your consent allows us to use artificial or prerecorded voice messages and automatic dialing technology for informational and account service calls, but not for telemarketing or sales calls. It may include contact from companies working on our behalf to service your account. Message and data rates may apply. You may contact us anytime to change these preferences.

Primary Borrower Mailing Address 1:

Primary Borrower Mailing Address 2:

City:

Property Mailing Address 1:

Property Mailing Address 2:

City:

AUTOMATIC PAYMENTS

Are payments for this loan scheduled as recurring payments through AutoPay, Online Banking or directly debited from Valley or any other bank?:

SERVICE MEMBER INFORMATION

Is any borrower an active duty Servicemember or was any borrower an active duty Servicemember within the last 12 months?:

Has the Service member recently been deployed away from their principal residence or recently received a Permanent Change of Station (PCS) order?:

PROPERTY INFORMATION

The Property is my:

DESCRIBE YOUR HARDSHIP

Please briefly describe to us your hardship related to the coronavirus. A Valley associate will follow-up with you to get more details.

Hardship Explanation:

(2000 Characters Remaining)

Date Hardship Began:

I believe that my situation is:

Before pressing SUBMIT, you must click and read the following Consent To Do Business Electronically and Receive Electronic Notices and Disclosures in Connection with your Mortgage Loan (the "Electronic Disclosure Agreement")

Do you consent to receive electronic notices and disclosures in connection with your mortgage loan?: