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Please complete the following as completely as possible. If an item does not apply, leave it blank. When you are finished, click on the Submit button at the bottom of the page. We will contact you soon!

Required General Information

Your First Name

Your E-Mail Address

Optional General Information

Your Last Name

Daytime Phone Evening Phone

Fax

Street Address

City, State, ZIP

What kind of home loan are you interested in?

New Home Purchase FIRST TIME HOME BUYER? Yes, first-time home buyer No, not first-time home buyer

Refinance DO YOU WANT CASH OUT? Yes, want cash out No, don't want cash out If yes, how much?

Please tell us about the home you will be financing.

Value of Home: Annual Property Tax (if known):

Annual Homeowner's Insurance Premium (if known):

TYPE OF DWELLING Single-family (including condo) Two to four units More than four units OWNER-OCCUPIED? Yes, owner-occupied Not owner-occupied

Please tell us about your personal finances. (All information is optional, but more information will result in a more accurate quotation.)

Monthly pre-tax income... You: Co-Borrower:

Monthly debt service... Credit Card(s): Car(s): Student Loan(s):

Credit history issues (check all that apply):

Late payments on mortgages

Late payments on credit cards and/or other loans

Collections/Litigation

Bankruptcy (if checked, please specify year)

If you consent to a credit check, please fill out the following information.

MAY WE OBTAIN A COPY OF YOUR CREDIT REPORT? Yes, you may obtain a copy of my credit report. No, please process my request without a credit report.

Your Full Name Your SS Number

Your Complete Address

Co-Borrower SS Number

Complete Address (if different)

Please be sure that you have entered your FIRST NAME and E-MAIL ADDRESS at the top of the form.