Borrower:

Co-Borrower:  

E-mail:

Current Street Address:

City:

State:

Zip Code:

Home Phone:

Work Phone: (Include extension if applicable)
Ext:

Use of Property:
Primary Residence       Second Home      Investment Property
Purchase Price OR Current Value of Property: 

Cash Down Payment: (If purchase)

Property Address:

Property City:

Property State:

Property Zip Code:

Property Type:
Single Family Condo/Townhouse Multi Family

Would you like to be referred to a Realtor in the area:
Yes      No

If refinancing or applying for 2nd mortgage please answer the following:

Type of Current Loan:
Conventional   FHA  VA   Other
Outstanding balance owed on 1st mortgage:

What is your Current Interest Rate?:

Current Monthly Payment:

Are Taxes Included in Monthly Payment: 
Yes      No   Annual Property Taxes
Do you currently have Mortgage Insurance?:
Yes      No
Do you have a 2nd Mortgage or a line of credit on the Subject Property?:
Yes      No    Amount of 2nd mortgage: 
Do you want to keep this loan or consolidate it with the First Mortgage? 
Keep    Consolidate

How would you rate your Credit?
I always pay on time   .                 I often pay late  
I sometimes pay late           .         I am delinquent now

Have you ever filed Bankruptcy:  No    Yes
If yes, what month and year was your Bankruptcy discharged?

Borrower Employment Status:               Co-Borrower Employment Status:
Salaried/Hourly Self Employed        Salaried/Hourly  Self Employed