This mortgage is for:
  Purchase
  Refinance

Is this for your primary residence?
  Yes
  No

Your current address:

Address
City
State/Province
Zip/Postal
Daytime Telephone
Evening Telephone
E-mail
Fax

How long have you been at this address?

Do you currently:
  Rent
  Own

What is your monthly payment?

BORROWER Name of Borrower: First:  Last:  Date of Birth (MM/DD/YYYY): Marital Status   Married   Separated   Unmarried (single, divorced or widowed) Years in School: Number of Dependants: Dependants Ages: Employers Name: Your Job Position: Work phone number: Are you self employed?   Yes   No How long have you been on this job?   Years   Months Your gross monthly income: Additional sources of income: Amount of additional income per month: Are you obligated to pay alimony, child support or separate maintenance? Yes   No If yes, Monthly Amount Are you a US citizen? Yes   No If not a US citizen, please list current status: Have you ever declared Bankruptcy? Yes   No If yes, in which year: What chapter: 7 11 13 Race/National Origin: (OPTIONAL) Social Security Number:

CO-BORROWER Name of Co-Borrower: First:  Last:  Date of Birth (MM/DD/YYYY): Marital Status   Married   Separated   Unmarried (single, divorced or widowed) Years in School: Number of Dependants: Dependants Ages: Employers Name: Your Job Position: Work phone number: Are you self employed?   Yes   No How long have you been on this job?   Years   Months Your gross monthly income: Additional sources of income: Amount of additional income per month: Are you obligated to pay alimony, child support or separate maintenance? Yes   No If yes, Monthly Amount Are you a US citizen? Yes   No If not a US citizen, please list current status: Have you ever declared Bankruptcy? Yes   No If yes, in which year: What chapter: 7 11 13 Race/National Origin: (OPTIONAL) Social Security Number If Co-borrower is at a different address than Borrower: Your current address: Address   City State/Prov. Zip/Postal Day Phone PM Phone E-mail Fax How long have you been at this address? Do you currently:   Rent   Own What is your monthly payment?

Assets: (enter amounts for those that will be used for home purchase)

Checking
Savings/CDs
Retirement
Mutual fund
Stocks/bonds
Other
Gift

Do you own other real estate?
  Yes   No

If yes:
 

Address
City
State/Province
Zip/Postal
Mortgage balance
Payment
Value
Property type: (2nd home, investment, etc.)

What is your purchase price range?
  From $ to $

What is the maximum you want your payment to be?
  $

Sales Associate Name:
Loan Officer Name:

Please choose desired AgentOwned Sales Office:
-- select an office --

Please add any information or comments that may help us obtain your loan approval:

Authorization to Release Income Information
Borrower/co-borrower understands and agrees that the loan application may be reviewed by any needed underwriting service to assist in the mortgage and homeowner insurance application processing. Borrower/co-borrower authorizes AgentOwned and its affiliated mortgage/insurance underwriters to obtain Borrower's/co-borrower's credit reports, information regarding Borrower's/co-borrower's employment, income, assets and liabilities and other information about Borrower/co-borrower that they may require to process the application or to review Borrower's/co-borrower's loan in connection with a potential sale. Borrower/co-borrower understands these inquiries into credit will appear on their permanent credit file.
I Agree I Do Not Agree