Borrower

Co-Borrower

Names

Social Security Number

Home phone number

Work phone number

Cell phone number

Employer name

Employer address

Employer city, state, zip code

Title

Are you self-employed?

Yes  No

Yes  No

Years at current job

Gross monthly income

Date of birth (MM/DD/YY)

Amount in savings

Amount in retirement

Property street address

Property city, state, zip code

Purchase or refinance?

Purchase  Refinance

Year purchased

Purchase price

Estimated present value of property

Is this your primary residence?

Yes  No

Property type

Please Select Single Family Home Townhouse Condo

Are you married?

Yes  No

If you are married, are both names on title?

Yes  No

Current mortgage $

Current payment $

Term

Rate

Second mortgage $

Payment $

Term

Rate

Is the second mortgage an equity line of credit?

Yes  No

Do you want cash out?  If so, how much?

Yes  No  

Total amount you want to refinance?

Are taxes and insurance included
in your current payment?

Yes  No

Do you want taxes and insurance
included in your new monthly payment?

Yes  No

Annual property taxes

Annual hazard insurance

Comments

At the close of this loan, we will donate $100
in your name to a charity.  Please choose
from the following charities:

Cystic Fibrosis Foundation
American Red Cross
American Heart Association
Make-A-Wish Foundation
American Cancer Society