DECLARATION OF INTENT TO REPAIR

This form is required—by completing this form, you verify your intent to repair the damage to your home. To avoid delays, please make sure all fields on this form are completed before you submit it.

Loan number:

Name(s) of customer(s):

Email address:

Preferred Phone number(s):

Property address:

Amount of claim check:

Cause of damage/loss:

I/We hereby certify that the insurance claim funds in the amount listed above are to be used to repair/restore the property to as good a condition or better than prior to the damage, that all repairs will be made in a timely manner and that no material or labor liens will occur as a result of the labor performed or the materials used.

I/We understand that a licensed contractor must be used to repair/restore the property.

Customer's Signature: Date:

Only one customer's signature is required, but if possible, please provide all customers' signatures.

Once you’ve completed this form, you can scan and upload it to InsuranceClaimCheck.com/Chase, a secure, Chase-approved site. You can also return it to us by mail or fax to:

Regular Mail:

Overnight mail:

Fax:

(Free of charge from

any Chase branch)