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CUSTOMER INFORMATION Your First Name Your Last Name Address City State - Select - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire NewJersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Home Phone ( ) - Work/Mobile Phone ( ) - Ext Email Best Contact Time - Select - Morning at Home Morning at Work Afternoon at Home Afternoon at Work Evening at Home Late Evening at Home LOAN INFORMATION Loan Purpose - Select - Refinance 1st Mortgage Refi 1st W/ Cash Out Refi 1st FHA Refi 1st VA Debt Consolidation Home Equity Line of Credit Purchase First Home Purchase Another Home Approximate Home Value 1,000,000-1,024,999 975,000-999,999 950,000-974,999 925,000-949,999 900,000-924,999 875,000-899,999 850,000-874,999 825,000-849,999 800,000-824,999 775,000-799,999 750,000-774,999 725,000-749,999 700,000-724,999 675,000-699,999 650,000-674,999 625,000-649,999 600,000-624,999 575,000-599,999 550,000-574,999 525,000-549,999 500,000-524,999 475,000-499,999 470,000-474,999 465,000-469,999 460,000-464,999 455,000-459,999 450,000-454,999 445,000-449,999 440,000-444,999 435,000-439,999 430,000-434,999 425,000-429,999 420,000-424,999 415,000-419,999 410,000-414,999 405,000-409,999 400,000-404,999 395,000-399,999 390,000-394,999 385,000-389,999 380,000-384,999 375,000-379,999 370,000-374,999 365,000-369,999 360,000-364,999 355,000-359,999 350,000-354,999 345,000-349,999 340,000-344,999 335,000-339,999 330,000-334,999 325,000-329,999 320,000-324,999 315,000-319,999 310,000-314,999 305,000-309,999 302,500-304,999 300,000-302,499 297,500-299,999 295,000-297,499 292,500-294,999 290,000-292,499 287,500-289,999 285,000-287,499 282,500-284,999 280,000-282,499 277,500-279,999 275,000-277,499 272,500-274,999 270,000-272,499 267,500-269,999 265,000-267,499 262,500-264,999 260,000-262,499 257,500-259,999 255,000-257,499 252,500-254,999 250,000-252,499 247,500-249,999 245,000-247,499 242,500-244,999 240,000-242,499 237,500-239,999 235,000-237,499 232,500-234,999 230,000-232,499 227,500-229,999 225,000-227,499 222,500-224,999 220,000-222,499 217,500-219,999 215,000-217,499 212,500-214,999 210,000-212,499 207,500-209,999 205,000-207,499 202,500-204,999 200,000-202,499 197,500-199,999 195,000-197,499 192,500-194,999 190,000-192,499 187,500-189,999 185,000-187,499 182,500-184,999 180,000-182,499 177,500-179,999 175,000-177,499 172,500-174,999 170,000-172,499 167,500-169,999 165,000-167,499 162,500-164,999 160,000-162,499 157,500-159,999 155,000-157,499 152,500-154,999 - Select - 150,000-152,499 147,500-149,999 145,000-147,499 142,500-144,999 140,000-142,499 137,500-139,999 135,000-137,499 132,500-134,999 130,000-132,499 127,500-129,999 125,000-127,499 122,500-124,999 120,000-122,499 117,500-119,999 115,000-117,499 112,500-114,999 110,000-112,499 107,500-109,999 105,000-107,499 102,500-104,999 100,000-102,499 97,500-99,999 95,000-97,499 92,500-94,999 90,000-92,499 87,500-89,999 85,000-87,499 82,500-84,999 80,000-82,499 77,500-79,999 75,000-77,499 0-74,999 Credit Rating - Select - Excellent Good Fair Poor Approximate Loan Amount Desired 1,000,000-1,024,999 975,000-999,999 950,000-974,999 925,000-949,999 900,000-924,999 875,000-899,999 850,000-874,999 825,000-849,999 800,000-824,999 775,000-799,999 750,000-774,999 725,000-749,999 700,000-724,999 675,000-699,999 650,000-674,999 625,000-649,999 600,000-624,999 575,000-599,999 550,000-574,999 525,000-549,999 500,000-524,999 475,000-499,999 470,000-474,999 465,000-469,999 460,000-464,999 455,000-459,999 450,000-454,999 445,000-449,999 440,000-444,999 435,000-439,999 430,000-434,999 425,000-429,999 420,000-424,999 415,000-419,999 410,000-414,999 405,000-409,999 400,000-404,999 395,000-399,999 390,000-394,999 385,000-389,999 380,000-384,999 375,000-379,999 370,000-374,999 365,000-369,999 360,000-364,999 355,000-359,999 350,000-354,999 345,000-349,999 340,000-344,999 335,000-339,999 330,000-334,999 325,000-329,999 320,000-324,999 315,000-319,999 310,000-314,999 305,000-309,999 300,000-304,999 295,000-299,999 292,500-294,999 290,000-292,499 287,500-289,999 285,000-287,499 282,500-284,999 280,000-282,499 277,500-279,999 275,000-277,499 272,500-274,999 270,000-272,499 267,500-269,999 265,000-267,499 262,500-264,999 260,000-262,499 257,500-259,999 255,000-257,499 252,500-254,999 250,000-252,499 247,500-249,999 245,000-247,499 242,500-244,999 240,000-242,499 237,500-239,999 235,000-237,499 232,500-234,999 230,000-232,499 227,500-229,999 225,000-227,499 222,500-224,999 220,000-222,499 217,500-219,999 215,000-217,499 212,500-214,999 210,000-212,499 207,500-209,999 205,000-207,499 202,500-204,999 200,000-202,499 197,500-199,999 195,000-197,499 192,500-194,999 190,000-192,499 187,500-189,999 185,000-187,499 182,500-184,999 180,000-182,499 177,500-179,999 175,000-177,499 172,500-174,999 170,000-172,499 167,500-169,999 165,000-167,499 162,500-164,999 160,000-162,499 157,500-159,999 155,000-157,499 152,500-154,999 150,000-152,499 147,500-149,999 145,000-147,499 142,500-144,999 140,000-142,499 137,500-139,999 135,000-137,499 132,500-134,999 130,000-132,499 127,500-129,999 125,000-127,499 122,500-124,999 120,000-122,499 117,500-119,999 115,000-117,499 112,500-114,999 - Select - 110,000-112,499 107,500-109,999 105,000-107,499 102,500-104,999 100,000-102,499 97,500-99,999 95,000-97,499 92,500-94,999 90,000-92,499 87,500-89,999 85,000-87,499 82,500-84,999 80,000-82,499 77,500-79,999 75,000-77,499 72,500-74,999 70,000-72,499 67,500-69,999 65,000-67,499 62,500-64,999 60,000-62,499 Current Interest Rate 14 - 14.24 13.75 - 13.99 13.5 - 13.74 13.25 - 13.49 13 - 13.24 12.75 - 12.99 12.5 - 12.74 12.25 - 12.49 12 - 12.24 11.75 - 11.99 11.5 - 11.74 11.25 - 11.49 11 - 11.24 10.75 - 10.99 10.5 - 10.74 10.25 - 10.49 10 - 10.24 9.75 - 9.99 9.5 - 9.74 9.25 - 9.49 9 - 9.24 8.75 - 8.99 8.5 - 8.74 8.25 - 8.49 8 - 8.24 7.75 - 7.99 7.5 - 7.74 7.25 - 7.49 - Select - 7 - 7.24 6.75 - 6.99 6.5 - 6.74 6.25 - 6.49 6 - 6.24 5.75 - 5.99 5.5 - 5.74 5.25 - 5.49 5 - 5.24 % Approximate 1st Mortgage Balance 1,000,000-1,024,999 975,000-999,999 950,000-974,999 925,000-949,999 900,000-924,999 875,000-899,999 850,000-874,999 825,000-849,999 800,000-824,999 775,000-799,999 750,000-774,999 725,000-749,999 700,000-724,999 675,000-699,999 650,000-674,999 625,000-649,999 600,000-624,999 575,000-599,999 550,000-574,999 525,000-549,999 500,000-524,999 475,000-499,999 470,000-474,999 465,000-469,999 460,000-464,999 455,000-459,999 450,000-454,999 445,000-449,999 440,000-444,999 435,000-439,999 430,000-434,999 425,000-429,999 420,000-424,999 415,000-419,999 410,000-414,999 405,000-409,999 400,000-404,999 395,000-399,999 390,000-394,999 385,000-389,999 380,000-384,999 375,000-379,999 370,000-374,999 365,000-369,999 360,000-364,999 355,000-359,999 350,000-354,999 345,000-349,999 340,000-344,999 335,000-339,999 330,000-334,999 325,000-329,999 320,000-324,999 315,000-319,999 310,000-314,999 305,000-309,999 302,500-304,999 300,000-302,499 297,500-299,999 295,000-297,499 292,500-294,999 290,000-292,499 287,500-289,999 285,000-287,499 282,500-284,999 280,000-282,499 277,500-279,999 275,000-277,499 272,500-274,999 270,000-272,499 267,500-269,999 265,000-267,499 262,500-264,999 260,000-262,499 257,500-259,999 255,000-257,499 252,500-254,999 250,000-252,499 247,500-249,999 245,000-247,499 242,500-244,999 240,000-242,499 237,500-239,999 235,000-237,499 232,500-234,999 230,000-232,499 227,500-229,999 225,000-227,499 222,500-224,999 220,000-222,499 217,500-219,999 215,000-217,499 212,500-214,999 210,000-212,499 207,500-209,999 205,000-207,499 202,500-204,999 200,000-202,499 197,500-199,999 195,000-197,499 192,500-194,999 190,000-192,499 187,500-189,999 185,000-187,499 182,500-184,999 180,000-182,499 177,500-179,999 175,000-177,499 172,500-174,999 170,000-172,499 167,500-169,999 165,000-167,499 162,500-164,999 160,000-162,499 157,500-159,999 155,000-157,499 152,500-154,999 150,000-152,499 147,500-149,999 145,000-147,499 142,500-144,999 140,000-142,499 137,500-139,999 135,000-137,499 132,500-134,999 130,000-132,499 127,500-129,999 125,000-127,499 122,500-124,999 120,000-122,499 117,500-119,999 115,000-117,499 112,500-114,999 - Select - 110,000-112,499 107,500-109,999 105,000-107,499 102,500-104,999 100,000-102,499 97,500-99,999 95,000-97,499 92,500-94,999 90,000-92,499 87,500-89,999 85,000-87,499 82,500-84,999 80,000-82,499 77,500-79,999 75,000-77,499 72,500-74,999 70,000-72,499 67,500-69,999 65,000-67,499 62,500-64,999 60,000-62,499 Type of House - Select - Single Family Residence Condo Townhouse 2-4 Plex Other By submitting this form you authorize us to send your loan request to multiple qualified lenders, who will be calling you with no obligation mortgage quotes.