Borrower's Information

Borrower's First Name:            M.I. Last:

Social Security Number:                     Date of Birth:

Co-Borrower's First Name:      M.I. Last:

Social Security Number:                     Date of Birth:

Home Address:                        

City: State:  Select ------ US States ------ Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New York New Hampshire New Jersey New Mexico North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennesee Texas Utah Vermont Virginia Washington West Virginia Wyoming Wisconsin Washington D.C. Zip Code:

Home Phone:

Work Phone: His  Hers

Best Time To Be Reached: At Home  At Work

E-Mail Address:                  

Property Information

Property Address (if different from above):

City: State:  Select ------ US States ------ Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New York New Hampshire New Jersey New Mexico North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennesee Texas Utah Vermont Virginia Washington West Virginia Wyoming Wisconsin Washington D.C. Zip Code:

How long have you lived at your current address:   Home Type: Single Family Condo Town House Mobile Home 2 Unit 3-4 Unit 5+ Unit Other

Purchase Price of Home:       Estimated Appraised Value of Home:

First Mtg Company:                                   Estimated Balance:

Monthly Payment:                 Does this include Taxes & Insurance? Yes No

Interest Rate: Fixed Adjustable    

Second Mtg/Lien Company:                    Estimated Balance:  

Monthly Payment:                  

Interest Rate: Fixed Adjustable

Have you ever been 30 days late on your mortgage payment in the last 12 months? 0 times 1 time 2 times 3 times 4+ times

Have you claimed bankruptcy or foreclosure in the last two years? Yes  No

How would you rate your overall credit?  Excellent Good Fair Poor

Employment Information

Borrower Employer:            Position:

Length of Employment:    

Gross Monthly Income:  

Co-Borrower Employer:      Position: 

Length of Employment:     

Gross Monthly Income:  

Loan Purpose

I am interested in receiving a free quote to (check all that apply):

Purchase New Home         Purchase Rental House     Refinance Current Home

Refinance Rental House   Do Home Improvements   Consolidate Bills

Receive Cash Out              Lower Payments                 Lower Interest Rate

Shorten Term                       Payoff Land Contract        Purchase Land

Please include any other information you would like below:

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