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Bill Consolidation
Name - First, Middle Initial, Last

Social Security #
Date of Birth
Street address
Work Phone
Home Phone
E-mail
City
Zip
FAX
State
How long at this address?
Current Employer
Job Title
Monthly Gross Income
Other Income
Time at your current job

Job Status:
Salaried
Self Employed

About the Property to be Financed:
Type of Property - Description
Loan Program of Interest
Location of Property City: State:
For Purchase, Construction, Rehab Loans:
Proposed Settlement Date
Realtor Information - Description
Purchase price of home will be (approx.)
You have my permission to call the Realtor at (phone number)
Preferred down payment (in percent)
Actual/Proposed annual property taxes:
Annual homeowners insurance premium (if known)
Annual flood insurance premium (if required & known)
For Loan Refinancing: (including 1st mortgage, 2nd mortgage, equity line and home improvement)
Age of property
Property Location (Street/City)
Original purchase price of the property:
Estimated value of property today
Balance of existing loans on the property
1st Mortgage $ 2nd Mortgage $ 3rd Mortgage $
Interest Rate
1st Mortgage % 2nd Mortgage % 3rd Mortgage %
Purpose for refinancing: (You may check more than one by holding the control key down.)
*Cash out amount needed
*Description of Other
Annual property taxes $
Annual homeowners insurance premium $
Annual flood insurance premium $ (if required)
Current total monthly payment $ Includes: taxes insurance

Other Information:


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