CUSTOMER INFORMATION Your First Name Your Last Name Address City State - Select - AK 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 Zip Code Home Phone ( ) - Work/Mobile Phone ( ) - Ext Email Best Contact Time - Select - Morning at Work Morning at Home Evening at Home Evening at Work Afternoon at Home Afternoon at Work LOAN INFORMATION Loan Purpose - Select - Home Purchase Home Refinance Debt Consolidation Home Improvement Other Approximate Home Value -select- 50000 - 75000 75000 - 100000 100000 - 125000 125000 - 150000 150000 - 175000 175000 - 200000 200000 - 225000 225000 - 250000 250000 - 300000 300000 - 350000 350000 - 500000 5000000 - 1000000 Credit Rating - Select - Excellent Good Fair Poor Approximate Loan Amount Desired -select- 50000 - 75000 75000 - 100000 100000 - 125000 125000 - 150000 150000 - 175000 175000 - 200000 200000 - 225000 225000 - 250000 250000 - 300000 300000 - 350000 350000 - 500000 5000000 - 1000000 Current Interest Rate -Select- 0 - 1 2 - 3 3 - 4 4 - 5 5 - 6 6 - 7 7 - 8 8 - 9 9 - 10 10 - 11 11 - 18 % Approximate 1st Mortgage Balance -select- 50000 - 75000 75000 - 100000 100000 - 125000 125000 - 150000 150000 - 175000 175000 - 200000 200000 - 225000 225000 - 250000 250000 - 300000 300000 - 350000 350000 - 500000 5000000 - 1000000 Paid in Full Type of House Single Family Multi-Family Manufactured Home Condo Town Home Other Sorry, we do not accept mobile home and commerical loan requests.