Personal Information   *Highlighted fields are REQUIRED  

First Name
Middle Name
Last Name
Email
Home Phone
Cell Phone
Work Phone
Marital Status
Are you a U.S. citizen?
Date of Birth (MM/DD/YYYY)
Social Security Number
Number of Dependents

Current Address

Address
City
State
Zip
Time at this Address
Years
Months
 
Rent or Own
 
If renting, amount
$

Subject Property

Purpose of Loan
Property Type
Occupancy
Purchase Price/Value:
$
Loan Amount
$
Subject Property Address
City
State
Zip

Employment Information

Current Employer
Address
City
State
Zip
Time at Employer
Years
Months

Income

Income
$
Other
$

Assets

Checking
$
Savings
$
Other
$
 
Loan Officer

Information for Government Monitoring Purposes

The following information is requested by the federal government for certain types of loans related to a dwelling in order to monitor the lender's compliance with equal credit opportunity, fair housing, and home mortgage disclosure laws. You are not required to furnish this information, but are encouraged to do so. You may select one or more designations for "Race." The law provides that a lender may not discriminate on the basis of this information, or on whether you choose to furnish it. However, if you choose not to furnish the information and you have made this application in person, under federal regulations the lender is required to note ethnicity, race, and sex on the basis of visual observation or surname. If you do not wish to furnish the information, please check below.

Sex:
Ethnicity:
Race:

Co-Borrower

Do you have a co-borrower?