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Borrower Information
First Phone(H)
Middle Phone(W)
Last Email(Req'd)
  Current street address where you now reside:
Address
City State Zip    Yes  No
Marital Status? Do you own this home?
Years of school? Years at this address?
If less than 2 yrs please enter your previous address and how long you were there:
Social Security#:

Date of Birth: (mm/dd/yy)
Certified Secure Data
Co-Borrower Information
First Phone(H)
Middle Phone(W)
Last Email(Req'd)
  Current street address where you now reside:
Address
City State Zip    Yes  No
Marital Status? Do you own this home?
Years of school? Years at this address?
If less than 2 yrs please enter your previous address and how long you were there:
Social Security#:

Date of Birth: (mm/dd/yy)
Certified Secure Data
Borrower Employment Information
Employer
Employer Address Title
     
City State     Zip
Phone Salary (Annual)
Start Date Bus. Type

If you were with this company for less than 2 years please provide the following:

 

 Previous Employer's address
Previous Employer
Title Salary (Annual)
From to Bus. Type
 
Co-Borrower Employment Information
Employer
Employer Address Title
     
City State     Zip
Phone Salary (Annual)
Start Date Bus. Type

If you were with this company for less than 2 years please provide the following:

 

 Previous Employer's address
Previous Employer
Title Salary (Annual)
From to Bus. Type
 
Monthly Income and Combined Housing Expense Information
Gross Monthly Income Borrower Co-
Borrower 		Total Combined
Monthly
Housing
Expense 		Present
Base Employment Income* $ $ $ Rent $
Overtime $ $ $ 1st Mort. (P & l) $
Bonuses $ $ $ Other Financing $
Commissions $ $ $ Hazard Insurance $
Dividends/Interest $ $ $ Real Estate Taxes $
Net Rental Income $ $ $ Mortgage Insurance $
Other $ $ $ Other $
TOTAL $ $ $ TOTAL $
Please DO NOT enter commas
*Self Employed Borrower(s) may be required to provide additional documentation such as tax returns and financial statements.

Describe Other Income
Notice: Alimony, Child Support, or separate maintenance income need to be revealed if the Borrower (B) or Co-Borrower (C) does not choose to have it considered for repaying this loan.
B/C Description Monthly Amount    
 
 
 
Assets
This Statement and any applicable supporting schedules may be completed jointly by both married and unmarried Co-Borrowers if their assets and liabilities are sufficiently joined so that the Statement can be meaningfully and fairly presented on a combined basis; otherwise separate Statements and Schedules are required. If spouse completed the Co-Borrower section, this Statement and supporting schedules must be completed about that spouse also.
List checking and savings accounts below    
Name and address of Bank, S&L, or Credit Union: Account Number
 

Current Balance
$

Name and address of Bank, S&L, or Credit Union:
 

Account Number

Current Balance
$

Name and address of Bank, S&L, or Credit Union:
 

Account Number

Current Balance
$

Name and address of Bank, S&L, or Credit Union:
 

Account Number

Current Balance
$

Stocks, Bonds & Mutual Funds
(Company name/number & Description)
    Current Cash Value
  $
  $
 

$

  $
Life Insurance Face amount   $
Net Cash Value   $
Subtotal Liquid Assets   $
Vested interest in retirement fund   $
Net worth of business(es) owned   $
Other Assets (itemized)
    
$
Total Assets   $
Schedule of Real Estate Owned (Primary residence [PR], Second home [SH], Investment Property [IP])
Property Address Type Present
Market
Value		 Amount of Mortgage & Liens Gross
Rental
Income		 Mortgage
Payments
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
Declarations
  Borrower Co-Borrower
a. Are there any outstanding judgments against you? Y  N Y  N
b. Have you been declared bankrupt within the past 7 years? Y  N Y  N
c. Have you had property foreclosed upon or given title or deed in lieu thereof in the last 7 years? Y  N Y  N
d. Are you a party to a lawsuit? Y  N Y  N
e. Have you directly or indirectly been obligated on any loan which resulted in foreclosure, transfer of title in lieu of foreclosure, or judgment? Y  N Y  N
f. Are you presently delinquent or in default on any federal debt or any other loan, mortgage financial obligation, bond, or loan, guaranteed? Y  N Y  N
g. Are you obligated to pay alimony, child support, or separate maintenance? Y  N Y  N
h. Is any part of the down payment borrowed? Y  N Y  N
i. Are you a co-maker or endorser on a note? Y  N Y  N
j. Are you a US citizen? Y  N Y  N
k. Are you a permanent resident alien? Y  N Y  N
l. Do you intend to occupy the property as your primary residence? Y  N Y  N
m. Have you had ownership interest in a property in the last three years? Y  N Y  N
If either have answered YES to question m., the following two question must also be answered
    (1) What type of property did you own - primary residence (PR),
          second home (SH), or investment property (IP)?
    (2) How did you hold the title to the home - solely by yourself (S),
          jointly with your spouse (SP), or jointly with another person (O)?
I authorize this company to do an in-file credit report for pre-qualification Yes No
Who were you referred by?