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Homeowner Information First Name: Last Name: Middle Initial:     Current Address: City: State: -- Select State -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisianna Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Years at Address: Own Rent Living Rent Free   Home Phone: Work Phone: Cell Phone: Email Address:   Property Information   Same address as above   Property Address: City: State: -- Select State -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisianna Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: How many months are you behind on your mortage? Is there a co-borrower? Yes No Purchase Price or Estimated Value: $ Loan Ammount: $ Primary Residence Secondary Residence Investment Property Property Type: -- Select Type -- Single Family Residence 2 - 4 Family Residence Townhouse Condominium Co-op Monthly Real Estate Taxes: $ Monthly Association Dues / Monthly Maintanance: $   Employment Information & Liquid Assets   Are you Self Employed or Independent Contractor (1099)? Yes No Monthly Gross Income: $ Checking: $ Savings: $ Stocks & Bonds: $   Previous Address: (within last 2 years) City: State: -- Select State -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisianna Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:   Borrower Marital Status: Married Unmarried Separated Borrower Social Security Number: - -   Declarations   Bankrupcy: (past 7 years) Yes No Additional Comments: Foreclosure: (past 7 years) Yes No Federal Delinquency / Lien Yes No