Name: ____________________________  E-mail: _________________________

SS #: _______-______-________

Home Phone: (______)_____________   Business Phone: (______)_________

Best Time To Call: ______________   Age: _____  Marital Status: ________ 

Current Address: _________________  Previous Address:__________________

__________________________________  __________________________________

City: _______________  State: ____  City: _______________  State: _____

Zip: ___________                    Zip: ___________

Time at residence: ___yrs ___mos    Time at residence: ___yrs ___mos

# of dependents: _____  Ages: _____________________

Current Employer: ________________  Previous Employer: ________________

Address: _________________________  Address: __________________________

City: _______________  State: ____  City: ________________ State:______

Zip: ______  Monthly Income: _____  Zip: _______  Monthly Income:______

Years/months on job: _____________  Years/months on job: _____________

Other Income: __________________________________________________________

Co-Borrower: _____________________  E-mail: _________________________

SS #: _______-______-________

Home Phone: (______)______________  Business Phone: (______)_________

Best Time To Call: _______________  Age: _____  Marital Status: ________ 

Current Address: _________________  Previous Address:__________________

__________________________________  __________________________________

City: _______________  State: ____  City: _______________  State: _____

Zip: ___________                    Zip: ___________

Time at residence: ___yrs ___mos    Time at residence: ___yrs ___mos

# of dependents: _____  Ages: _____________________

Current Employer: ________________  Previous Employer: ________________

Address: _________________________  Address: __________________________

City: _______________  State: ____  City: _______________ State:_______

Zip: ______  Monthly Income: _____  Zip: _______  Monthly Income:______

Years/months on job: _____________  Years/months on job:_______________

Other Income: __________________________________________________________

Subject Property Address: ______________________________________________

Purpose of Loan: ____ Purchase       ____ Refinance  

                 ____ Construction   ____ Equity/Second Mortgage

Property will be: _____ Primary Residence  _____ Secondary Residence

                  _____ Investment         _____ Commercial

Loan Type: _____ Conventional  _____ VA  _____ FHA  _____ Other

Purchase Price: _________________    Down Payment: _____________________

Property Value: _________________    Equity: ___________________________

Balance of first mortgage: ______________  Rate: ________

Payment on first mortgage: ______________

Balance of second mortgage: _____________  Rate: ________

Payment on second mortgage: _____________

Accepted Offer: _______  Realtor: _______________  Phone: (____)________

Bank: __________________  Account #: _____________ Balance: ____________

Bank: __________________  Account #: _____________ Balance: ____________

Bank: __________________  Account #: _____________ Balance: ____________

Other: _________________  Account #: _____________ Balance: ____________

Real Estate values: ____________  ______________  _______________

Auto: _____________ Value: ________ Auto: ______________ Value:_________

Household: ___________________  Other Asset: ___________________________

                                                  Borrower   Co-Borrower

Are there any outstanding judgments against you?   Yes   No    Yes   No

Have you declared bankruptcy within the last 
7 years?                                           Yes   No    Yes   No

Have you had property foreclosed upon within the
last 7 years?                                      Yes   No    Yes   No

Are you a party to a lawsuit?                      Yes   No    Yes   No

Have you directly or indirectly been obligated on
any loan which resulted in foreclosure, transfer
of title in lieu of foreclosure, or judgment?      Yes   No    Yes   No

Are you presently delinquent or in default on
any Federal debt or any other loan, mortgage,
financial obligation, bond or loan guarantee?      Yes   No    Yes   No

Are you obligated to pay alimony child support
or separate maintenance?                           Yes   No    Yes   No

Is any part of the down payment borrowed?          Yes   No    Yes   No

Are you the co-maker or endorser on a note?        Yes   No    Yes   No

Are you a U.S. citizen?                            Yes   No    Yes   No

Are you a permanent resident alien?                Yes   No    Yes   No

Do you intend to occupy the property as your
primary residence?                                 Yes   No    Yes   No

Have you had an ownership interest in a property
in the last 3 years?                               Yes   No    Yes   No

If you answered yes to the last question, answer the two questions below:

What type of property did you own?

_____ Principle Residence  _____ Second home  _____ Investment Property

How did you hold title to the property?

_____ Solely  _____Jointly with spouse  _____Jointly with other person