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Home Owners Only Please
Date:
Source:
Internet
Direct Marketing
Word of Mouth
Phone Book
Advertisement
Other
Borrower:
S.S.#:
D.O.B.:
Co-Borrower:
S.S.#:
D.O.B.:
Street Address:
City:
County:
State:
Zip:
Home Phone:
Work phone:
FAX:
E-mail:
Employment
Borrower
Employer:
Address:
Position/Title:
Years There:
Gross Salary:
Prior Employment if
above less than 1 years:
Other Income:
Source:
Co-Borrower
Employer:
Address:
Position/Title:
Years There:
Gross Salary:
Prior Employment if above less than 1 years
Other Income:
Source:
Number of Dependants:
Ages:
Property Information
YR. Purchased:
Paid:
House Value:
1st Mortgage Balance:
$
1st Payment:
$
1st Rate:
%
2nd Mortgage Balance:
$
2nd Payment:
$
2nd Rate:
%
Current Mortgage Holder 1st:
Current Mortgage Holder 2nd:
Purpose of This Loan:
Debt Consolidation
Refinance 1st Mortgage
Refinance 2nd Mortgage
Refinance Both Mortgages
Home Improvement
Other
Loan Amount Requested:
Credit
Credit Rating:
Excellent
Good
Fair
Poor
Explanation of Credit
Prior Bankruptcy?
Yes
No
Credit Since Bankruptcy:
Good
Fair
Poor
Unsatisfied Liens or Judgements:
Yes
No
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