Contact Information

Are you a home owner? Yes No New Purchase

Primary Applicant Name:

Co-Applicant Name:

Street Address:

City:

State: Zip:

Home Phone:

Work Phone:

Mortgage Information

Property Type: Single Family Residence Condominium Townhouse 1-4 Units

Original Purchase Price:

(example 120,K)

Year Acquired:

Estimated Property Value (must be at least $50,K):

Amount owed on 1st Mortgage:

Current interest rate on 1st Mortgage:

Fixed or Adjustable: Fixed Adjustable Fixed with ballon

Monthly Payment:

Amount owed on 2nd Mortgage:

Current interest rate on 2nd Mortgage:

My 2nd is Fixed or Adjustable: NA Fixed Adjustable

Monthly Payment on 2nd

Current Employer:

Years with current Employer:

Gross Yearly Income:

Credit Rating: make your best guess: Excellent Good Fair Poor

Best time to contact you: E-Mail Morning at Work Afternoon at Work Evening at Work Morning at Home Afternoon at Home Evening at Home

Type of Loan Desired: A new first mortgage Second Mortgage Debt Consolidation Refinance Refinance with Cash Out Home Equity Line of Credit

Amount Desired (must be at least $20,K):

Your E-Mail Address:

Please verify. Thanks!

Current Loan Needs:

i.e. Pay off bills, lower interest rate, or debt consolidation.

Will explain when contacted.