E-Mail Address

Day Telephone

Address

Evening Telephone

City

Fax Number

Purchase Price
(If you are buying this home)

Estimated Value of Your Home
(If you are refinancing)

$

This loan be placed on your:

Primary Residence

Vacation Home

Rental Property

Loan Amount (Amount you wish to borrow)

$

Your current monthly salary from all sources
$

Your monthly commissions or bonuses averaged for the last two years, if any
$

Current monthly financial obligations (minimum $ due)
$

Your total liquid assets (i.e. checking, savings, stocks, bonds, TRA's, CD's, money market accounts, 401K plans, etc.) that have been under your control for at least the last 90 days
$