| From: |
Title: |
| Phone: |
Fax: |
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| Borrower Name: |
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| E-Mail Address: |
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| Home Phone: |
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| Work Phone: |
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| Date of Birth: |
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| Marital Status: |
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| Present Address: |
Own Rent Number of Years
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| Street Address #1: |
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| Street Address #2: |
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| City: |
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| State: |
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| Zip: |
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| How would you rate your credit history? |
Excellent
Good
Issues |
| Explain Issues: |
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| Co-Borrower Name: |
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| Home Phone: |
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| Work Phone: |
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| Date of Birth: |
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| Marital Status: |
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| Present Address: |
Own Rent Number of Years
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| Street Address #1: |
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| Street Address #2: |
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| City: |
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| State: |
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| Zip: |
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| How would you rate your credit history? |
Excellent
Good
Issues |
| Explain Issues: |
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| Purpose of the loan: |
Purchase
Refinance
Home Equity
Construction |
Type of loan requested: |
Conventional
FHA
VA |
Property will be: |
Primary Residence
Secondary Home
Investment Property |
| Amount of Loan Requested: |
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| Monthly Income: |
| Borrower |
Co-Borrower |
Total |
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| Base Employment Income: |
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| Overtime: |
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| Bonuses: |
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| Commissions: |
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| Other: |
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| Total: |
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| Combined Monthly Obligations |
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| Rent Payments : |
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| Mortgage Payments : |
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| Total Credit Card Payment: |
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| Other Payments : |
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| Total: |
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| Borrower Self-employed |
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| Co-Borrower Self-employed |
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| Comment or Referral By: |
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