Please provide us with the information below so we can begin processing your request for your payment deferral.

  • OK Contact Name is required
  • Contact Phone Number

    - -
    OK Contact Phone Number is required
  • OK Borrower is required
  • If Applicable OK Borrower/Guarantor Name(s) (If Applicable) is required
  • If Applicable OK Borrower/Guarantor Name(s) (If Applicable) is required
  • If Applicable OK Borrower/Guarantor Name(s) (If Applicable) is required
  • OK Loan Number is required
  • OK Current/Property Address is required
  • OK City is required
  • OK State is required
  • OK Zip is required

E-Sign Consent

    OK By proceeding with your request and checking this box you represent and warrant that (i) you have read and understand the E-Sign Authorization and Disclosure (ii) you agree to accept the documents in an electronic format, and (iii) you agree that you have the required hardware and software necessary to access the account disclosures and to retain a copy of them. is required
  • By completing this form, you are requesting Fidelity Bank (“Fidelity”) to temporarily defer payment of your term loan listed above for a maximum of three (3) months. You acknowledge the request is being made due to temporary financial difficulties you are experiencing as a result of COVID-19. Your completion of the online form for the deferral without Fidelity requiring the submission of all of the information necessary for other potential loss mitigation options constitutes, based on Fidelity’s evaluation, an incomplete loss mitigation application. These additional options require the completion of a loss mitigation application in order to receive an evaluation of all loss mitigation options available to you. Your request is subject to Fidelity’s credit review process. You will be advised within 14 days of submission of this form if your request has been approved. If your request is approved by Fidelity, you understand and agree to the following terms and conditions:

    Interest, calculated in accordance with the applicable provisions of your loan’s promissory note (“Note”), will continue to accrue during the time period for which the payment is being deferred. You are requesting Fidelity to advance the due date on each eligible loan which you have indicated above. The loan deferral may result in an increase in the period of time required to pay off the loan balance in accordance with the payment terms contained in the Note. Based on the date of the submission of this form and approval by Fidelity, the maturity date on your Note will be extended for up to three (3) months. If there is more than one borrower on the loan, you represent and warrant that you have informed all borrowers and guarantors of the deferred payment(s) and all other borrowers and guarantors agree to the deferred payment(s). You agree to indemnify Fidelity for relying on this representation.

    You acknowledge that this deferment may cause an escrow shortage and/or deficiency upon your next annual escrow analysis and may result in a higher monthly payment. For loans with only interest due upon each regular periodic payment, you acknowledge that this deferment may cause an increase in your first payment due after the deferment period ends. For loans with principal and interest due upon each regular periodic payment, you acknowledge that once the regular periodic payments provided in the Note recommence, the portion of the payment allocated to accrued, unpaid interest will generally be higher until the unpaid interest that accrued during the deferral period has been satisfied.


    This deferral shall not be deemed a novation of the Note. All other terms and conditions of the Note and other documents that are part of the entire agreement related to the loan listed above remain the same. If you have any defaults on the Note or related documents during the deferral period, this deferral may be terminated by Fidelity, at its sole discretion, without prior notice. The final payment may be larger than your regular monthly payment as a result of this payment deferral arrangement.

    You understand that escrow for flood insurance can NOT be waived and may need to be established on loans originated or extended on or after January 1, 2016 where the subject property is located in a Special Flood Hazard Area (SFHA) per federal regulations.

    • • The escrow amount for flood insurance will be added to the regular mortgage payment that you make to Fidelity Bank.
    • • The payments you make into the escrow account will accumulate over time and the funds will be used to pay your flood insurance policy when Fidelity Bank receives a notice from your flood insurance provider that the flood insurance premium is due.

    You authorize Fidelity to contact you regarding your request or your loan(s) at any cellular telephone number that you provide now or in the future. Your submission of this deferral request shall serve as your electronic signature for all purposes under applicable law. You agree to make yourself available upon Fidelity's request to manually sign this agreement in person no later than 180 days from the date of your electronic signature. This agreement is governed under the laws of the same state which laws govern the terms of the Note and/or mortgage evidencing the loan.


    OK I acknowledge that by submitting this form, I agree to the terms of the agreement stated above and my submission constitutes my electronic signature. is required

Please Note

    • • If you have recurring automatic transfers from other financial institutions for your loan payment(s), it is your responsibility to stop the transfer and restart the transfer. Any fees assessed from your other financial institution for doing this will not be refunded Fidelity.
    • • Your account must be in good standing to be eligible for this offer. This option is currently not available to loans serviced by Fidelity Bank but owned by another entity. If you fill out this form in error, we will contact you at the telephone number on file to discuss any options that may otherwise be available to you.
    • • You are not obligated to accept the deferral offered in which case you should not submit this form and should continue to make your regular payments. You must continue making the regular payments until the form has been received and Fidelity has had an opportunity to review, process it, and notify you of its decision.