BORROWER CO-BORROWER
(If different)
Full Name:
Address:
City, State, Zip
Home Phone:
Work Phone:
Best time to contact:
E-mail:
Social Security #:
Employers:
Employers' Phone Number:
Self employed ? Yes No Yes No
Length of Employment:
Gross Monthly Income:
Date of Birth:
My credit history is: excellent
good, but some lates
some credit problems
major credit problems
don't know 		excellent
good, but some lates
some credit problems
major credit problems
don't know
LOAN REQUEST
Amount Requested:
Type of loan:

IF PURCHASE

Purchase State:
Purchase Price :
Loan Amount :
Anticipated Closing Date:

IF REFINANCE

Street Address:
City, State, Zip Code:
Estimated Present Value:
Year Purchased:
Original Price:
Type of Property: Primary Second/Vacation Investment
LOAN INFORMATION
MORTGAGE BALANCES Amount: Held by: Payment:
First:
Second:
Other:

CREDITORS Amount Owed Monthly Payment Will you pay this off?
$ $ Yes No
$ $ Yes No
$ $ Yes No
$ $ Yes No
Other monthly debts and information - please describe
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