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The following is a collection of forms which may require completion, depending on your individual situation.  If you plan to initiate counseling remotely (by telephone or email), please complete the appropriate forms and fax, email or standard mail them to:


Mail: PO Box 9026, Hickory, NC  28603  Attn: Laurie Powell


Otherwise, the required forms may be completed during your first counseling session.

Intake Questionnaire
This form is used to gather information needed by WPCOG to begin loss mitigation counseling.

Fillable Budget Worksheet
This Excel Spreadsheet may be used to calculate your household budget.

WPCOG Third Party Release

This document is required for a WPCOG counselor to speak to your lender on your behalf.

Request for Modification and Affidavit (RMA)
This form is used to request a modification through the  Making Home Affordable Program.

Request for Transcript of Tax Return
Use form 4506-T to order a transcript or other return information free of Charge from the IRS.

Dodd-Frank Certification
The information in this form is requested by the federal government in accordance with the Dodd-Frank Wall Street Reform and Consumer Protection Act (Pub. L. 111-203).

Sample Profit and Loss Statement for Self-Employed Homeowners
A year-to-date income statement or most recent three complete months.

The Western Piedmont Council of Governments shall serve all local government members in Alexander, Burke, Caldwell and Catawba Counties with professional, cost-effective assistance on a variety of local, regional, state and federal issues and programs.

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Telephone: ​828.322.9191

Fax: 828.322.5991

Mailing: P.O. Box 9026 | Hickory, NC 28603
Location: 1880 2nd Avenue NW
Hickory, NC 28601

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This institution does not discriminate on the basis of race, color, national origin, sex, religion, age or disability in employment or the provision of services. Auxiliary aids and services for individuals with disabilities are available upon request. This institution is an equal opportunity provider.