| *Required
  Fields      **Numbers
  Only | 
| Name: | *  * | 
| Address: | * * | 
| City: | * * | 
| State (USA Only): | AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
* * | 
| Zip/Postal Code: | * * | 
| Home Phone: | * * | 
| Work Phone: | * * | 
| Email Address: | * | 
| Best Time to Call: | Morning at Home
Morning at Work
Afternoon at Home
Afternoon at Work
Evening at Home
Late Evening at Home | 
| Do You Own Your Home?: | Yes
No
 Mobile Homes DO NOT Qualify | 
| Property Value: | Must enter in
000's  (ex. 45000)* | 
| Property Type: | Single Family Residence
Condo
Townhouse
2-4 Plex
Other | 
| Purchase Price: |  | 
| Year Acquired: | * * | 
| 1st Mortgage Balance Owed: | **Enter in 000's
(ex.45000) - Enter 0 if none | 
| 1st Mortgage Interest Rate: | 10% or above 9.0
  - 9.49 9.5 - 9.99 8.5
  - 8.99 8.0 - 8.49 7.1 -
  7.49 7.5 - 7.99 Below
  7.0 None * | 
| Is 1st Adjustable or Fixed?: | Fixed
Adjustable
 * | 
| 2nd Mortgage Balance Owed: | **Enter in 000's
(ex.45000) - Enter 0 if none* | 
| Amount You Wish To Borrow: | 15,000 - 30,000
  30,000 - 45,000
  45,000 - 60,000
  60,000 - 75,000
  75,000 - 90,000
  90,000 - 110,000
  110,000 - 125,000
  125,000 & Up | 
| Employer: | * | 
| Monthly Gross Household Income: | ** | 
| Monthly Debt: | * | 
| Credit Rating: | Good
Fair
Poor
 * | 
| Loan Interested In: | Debt Consolidation
Second Mortgage
Home Improvement
Refinance
Purchase
 * | 
|  | 
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