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Date:	Loan Agent you spoke to::
PreQualification Equity Debt Consolidation Refinance
Amount Requested: Purpose:
Name: DOB: S.S Number:
Co-Applicant: DOB: S.S Number:
Address:
City: State: Zip:
Year Purchased: Amount Paid: Current Value:
1st Mortgage Holder: Balance: Payment:
Percentage Rate of Loan: % 15 YR. 20 YR. 30 YR/ARM OR FIXED
2nd Mortgage Holder: Balance: Payment:
Percentage Rate of Loan: % 15 YR. 20 YR. 30 YR/ARM OR FIXED
Prepayment Pentaly on 1st or 2 nd YES NO	Expiration: Amount:

Employer: Years: Annual Salary:

Home Phone: Business Phone:

How would you rate your credit? Fair Good Excellent

Have you ever filed Bankruptcy? YES NO If So, Year Discharged

Have you missed or been over 30 days late in the past year on your mortgage? YES NO

Have you been over 30 days late on any other debts? YES NO

What is you combined credit card debt? $

What is your combined monthly paymenty? $

Do you have an auto loan? YES NO Balance: $ Montly Payment: $

Do you have any other loans? YES NO Balance: $ Payment: $

Do you own any other property? YES NO Balance: $ Payments: $

If Yes, How much equity do you have? $

May we run a credit check? YES NO

How did you hear about us?:

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