Last Name First Name

Date of Birth SSN#

Address City

State Zip How Long

Phone Number Work Number

Most Recent Employer How Long

Monthly Income Before Taxes Position

Value of Home Balance$ Rate%

What is this loan for? Refinance Purchase

First time home buyer? Yes No

How long do you plan to stay in your home or loan? 1 year 5 years 10 years 15 years 20 years 25 years 30 years 35 years 40 years

Occupancy 5 Self Employed? Yes No

How would you assess your credit? Excellent Fair Poor

Check Your Priorities Below:

Get cash for any purchase

Lower overall monthly payments

Home Improvments

Pay off credit cards

Lower rate and payments

Pay for education