Name:

Home address:

City:  State:   Zip:

Home Telephone Number:

Work Telephone Number:

Email:

Best Time To Contact: Morning at work Morning at home Afternoon at work Afternoon at home Evening at work Evening at home

The following questions will help us determine which of our programs are best suited to your needs and how we can best help you. Please fill in all the fields.

1)  Please choose on of the following loans Please select one: Consolidate debt Refinance my mortgage Purchase a home I have another reason for obtaining a mortgage  

2)  Overall mortgage credit: I have never been late on my mortgage 30 days late 60 days late 90 days late I have been late over 90 days I am in foreclosure

3)  Have you ever declared bankruptcy? Never Within the last 12 months 13-24 months Over 2 years ago Over 7 years ago

4)  Do you own or rent your home? Own Rent  

5)  What is the estimated value of your property you own or want to purchase? 

6)  How much do you owe on your current mortgage? If renting, skip to line 11.

7)  What is your existing mortgage rate?

8)  What type of mortgage do you current have? 30 year fixed 15 year fixed Adjustable rate mortgage

9)  Do you have a second mortgage on this property?

10)  How much do you owe on your second mortgage?   

11) What are your total mortgage or rent payments each month?

12) What is your annual gross income?

13) What is the co-borrower's annual gross income?

14)  Amount new loan requested?