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Print and fill out the following information (asterisks fields are mandatory) and fax
to 952-856-4175.
Primary Borrower Information
(All Fields in bold and with an * are Required)
*First Name:
*Last Name:
Social Security Number: - -
*E-mail Address:
*Subject Property Address:
*City:
*State: AZ CO FL IA MN MT ND NV OK SD WY OTHER____________
*Zip:
County:
Employer:
Position:
*Gross Monthly Income: $
Other Monthly Income: $
Years Employed at Current Job:
Years in this Line of Work:
*Home Phone: - -
Work Phone: - -
Mobile Phone: - -
Co-Borrower Information
First Name:
Last Name:
Social Security Number: - -
Employer:
Position:
Gross Monthly Income: $
Gross Other Income: $
Years Employed at Current Job:
Years in this Line of Work:
Loan Information
Purpose of the Loan:
Debt Consolidation Loan Home Improvement Loan Refinance Loan Debt
Consolidation plus Home Improvement Loan
*Total Money Needed: $
*Length of time at Current Residence: 0 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15
16 17 18 19 20 year(s) 0 01 02 03 04 05 06 07 08 09 10 11 12 month(s)
Are you a previous home owner? Yes No
Purchase Price: $
*Estimated Current Market Value: $
Balance of First Mortgage: $
Balance of Second Mortgage: $
How would you rate your credit? Excellent Good Fair Average Poor
*Have you Ever Filed for Bankruptcy? Yes No
If yes, how long ago? 0 01 02 03 04 05 06 07 08 09 10 year(s) 0 01 02 03 04 05 06
07 08 09 10 11 12 month(s)
*How did you hear about us?
Additional Comments
