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Borrower First Name
Jr./Sr. (if applicable)
Co-Borrower First Name 
Co-Jr./Sr. (if applicable)
Borrower Last Name 
Co-Borrower Last Name (leave blank if same as Borrower)
E-mail Address (important)
Street Number 
Street Name 
Postal Code 
Home Phone -

Your approximate gross annual income?  .
Borrower $
Co-Borrower $
Borrower are you paid ? HourlySalary
Are you self employed? YesNo
Co-Borrower are you paid ? HourlySalary
Are you self employed? YesNo
How long have you been on your current job? .
Borrower Years
Co-Borrower Years

Type of residence you live in:
Single Family Townhome Condo 2-4 flat
Are you renting and wanting to purchase a home? YesNo
Current monthly rent(if applicable)  $
Approximate value of your home  $
Annual property taxes  $
Monthly assessments (if applicable) $
Approximate balance of your first mortgage  $
2nd mortgage (if applicable) $
Your monthly auto/truck payment?  $
Student loan payment?  $
Any other fixed installment or monthly payment?  $
In the last 2 years: .
Have there been any bankruptcys YesNo
Have there been any foreclosures YesNo

Please best describe your credit payment history in the last 24 months: example, have you been late more than 30 days on a mortgage or rent payment, or an installment loan such as a car or student loan payment, in addition, please consider revolving payments, such as credit cards:

Do you want to Refinance your current mortgage(s)? YesNo
Do you want to Purchase a home?  YesNo
Do you want to Consolidate your debt such as credit cards, etc.?  YesNo
Are you a veteran in search of a VA loan?  YesNo

Briefly describe below any other needs for us to consider below:

Please click on the SUBMIT button, and we will process the information you have stated.
A loan officer will contact you within 24 hours to discuss your request, and will be able to quote rates and fees to you. Thank you for taking the time to complete this form.