General Information
Name
Address
City
State
Zip
Home phone
Office phone
Fax
email
Best time to call
Your Home
Year purchased
Estimated value	$
Type of property	Single Family Residence Condominium 2-4 Unit Building (Other)
Current balance on your 1st mortgage	$
Type of loan	(Other) Fixed Variable Balloon
Current 1st mortgage monthly payment	$
Current 1st mortgage interest rate	%
Current balance on your 2nd mortgage	$
Type of loan	(Other) Fixed Variable Balloon
Current 2nd mortgage monthly payment	$
Current 2nd mortgage interest rate	%
Your Employment
Total household income	$
Borrower
Social Security Number
Self-employed
If not self-employed, how long have you been employed in the same industry?
Co-Borrower
Social Security Number
Self-employed
If not self-employed, how long have you been employed in the same industry?
Your Application
Purpose of Loan	Purchase Refinance Debt Consolidation Construction Loan Cash From Equity Other
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Amount Requested	$
Comments