(Part 1) Borrower Last Name  First Name  M. I. Social Security # Street Address City State, Zip ,   Own Rent     How Many Years? Telephone # Email Address     Co-Borrower Last Name  First Name  M. I. Social Security # Street Address City State, Zip ,   Own Rent     How Many Years? Telephone #     Loan Purpose Purchase Refinance/Lower Rate & Term Refinance/Cash Out Refinance/Debt Consolidation     (Part 2) Subject Property Information Estimated Fair Market Value Type of Property Single Family 2–4 Family Multi-Family Condo Co-op Street Address City State, Zip , Current First Mortgage Bank   Balance  Monthly Payment Current Second Mortgage Bank   Balance  Monthly Payment Yearly Taxes Yearly Home Owners Insurance Association Dues     (Part 3) Employment Information Self-Employed Yes   No Employer Years on Job Salary Prior Employer (If at current job less than 2 years) Years on job Salary     Co-Borrower Self-Employed Yes   No Employer Years on Job Salary Prior Employer (If at current job less than 2 years) Years on job Salary Other income type Yearly Amount

Licensed Mortgage Banker N.Y.S. Banking Department. Licensed Mortgage Banker CT. Licensed Mortgage Brokerage Business - Florida Dept. of Financial Regulation.