Date

    Time

    Loan Officer

    Purpose of Loan

    Primary Borrower

    DOB

    SSN

    Phone (H)

    Phone (W)

    Co-Borrower

    DOB

    SSN

    Phone (H)

    Phone (W)

    Current Address

    FOR PURCHASE (LISTED HOME)

    Home Type

    Estimate Market Value

    Home Address

    FOR REFINANCE

    Home Type

    Cash Out

    Amount

    Reason(s) for cash

    Estimate value of home

    Tax Value

    Year Purchased

    Year built

    Original cost

    How long in Home?

    Escrow

    Mortgate INS

    AMT PER MO

    Current mortgage holder

    Mortgage Type

    Interest Rate

    Year Left

    Balance

    MO PMT

    2nd mortgage/line of credit holder

    Mortgage Type

    Interest Rate

    Year Left

    Balance

    MO PMT

    EMPLOYMENT HISTORY: (BORROWER)

    Employer Name

    Employer Address

    Position/Title

    Years On Job

    Gross Income

    Months

    Year

    Pain On

    Previous employer/part time employment info:

    EMPLOYMENT HISTORY: (CO-BORROWER)

    Employer Name

    Employer Address

    Position/Title

    Years On Job

    Gross Income

    Months

    Year

    Pain On

    Previous employer/part time employment info:

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