Name:
Address:
City, State Zip:	... AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY ...
Home Phone:
Work Phone:
E-Mail
What type of loan do you need?	Please Select Purchase Refinance
How would you rate your credit?	Please Select Excellent Good Fair Poor
What is your gross household monthly income?	$
How are you paid?	Please Select W-2 Income Paid in Cash Self Employed
If Purchase: {please complete}
How much do you have to put down?	$
What size of montly payment can you afford?	$
Do you have a realtor?	Please Select Yes No
Have you found a house?	Please Select Yes No
How soon do you plan on buying?	days
If Refinance: {please Complete}
Mortgage Company Name:
Mortgage Company Phone:
Mortgae Balance:	$
Interest Rate:	%
Years you have had this loan:	years
Do you want?	Please Select Cash in hand Pay off bills Lower rate Combo of these
...................