* = Required Date Loan Amount Request Broker's Name Address City State Zip Code Country Phone Mobile Phone * Fax Email Address Broker Loan Fee Borrower's Name Borrower's Fico Score Current on Mortgage X30 X60 X90 Other Ever Declared Bankruptcy? Yes No Date of Bankruptcy Ever Discharged? Yes No Date of Discharge Guarantor(s) Cross Real Estate Collateral (value, equity, type, location) Property Name Address City State Zip Code Country Property Description Property Type Owner Occupied? Yes No Building Size No. of Units Occupancy Estimated Value As-Approved MV Property Income Net Income Date of Purchase Purchase Price Purpose of Loan Refinance Construction/Rehab Purchase Cashout Income Verification Full Document State Income Paper Supply Existing Debt & Rate % Payable to Term Needed (in months) Loan to Value (%) Estimated Interest Rate (%) Requested Closing Date Purposed Loan Proceeds Disbursements: Refinance Pay off Mortgage Taxes Others Cashout Closing Cost Loan Request Purchase Purchase Price Down Payment Second Finance Amount Financed Closing Cost Loan Request Exit Strategy Payoffs Collateral, Security & Source of Repayment Transaction Description Summary of Relevant Facts Submit