1. Type Of Transaction: (Purchase, Re-Fi Cash Out, Rate & Term Re-Fi)

Purchase: Down Payment: $

Re-Finance: Balance left on Mortgage: $

Purchase: Property full address including county and state, where client is shopping in:

Re-Finance: Address of Property:

2. Property Type: (Primary, Second Home or Investment)

3. Property Value:

4. Number of Units:

5. FICO Score:

6. Business Ownership %:

7. Average Monthly Deposits into Business Bank Account:

8. Has the merchant had a Bankruptcy or Foreclosure in the Las 24 Months?

Yes

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Owner Signature:

Print Name:

Date: