Mortgage Request Form

First and Last Name Only
City
State
Street Address
Zip
Work Phone	() - -
Home Phone	() - -
Type of House Owned or Want Buy
Current Value	(Example: 200000) (If purchase enter the value of the home you want)
Purchase Price	(Example: 200000) (If purchase enter the value of the home you want)
Total Mortgage Balance	(Existing 1st and 2nd, if you owe zero enter the number 1)
Current Interest Rate	For purchase leave blank
Fixed or Adjustable?	For purchase leave blank
Monthly Payment	(Current monthy payment or rent)
Behind on Payments?
How Would Your Rate Your Credit?
Place of Employment
Years There
Yearly Income
Best Time to Call
Loan Amount Desired	(Example: 200000) Minimum Loan Amount $25000
Type of Loan Desired [ Help ]
Email Address
Additional information that you think may be helpful (i.e. Indicate how much cash out or straight rate and term refinance or any other information that may be helpful. For Purchase -Indicate where you are in the buying process, i.e. offer accepted, in escrow, want pre-approval, just shopping)	(Maximum 255 characters)
Originator I.D.