Mortgage/Home Equity Inquiry Form Required Information Loan Information Are you applying as an individual or with a co-borrower? Individual Co-Borrower Loan Type Purchase New Construction Refinance HELOC Borrower Information First Name Middle Initial Last Name Select Suffix I II III IV Jr. Sr. Suffix Home Address City Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey 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 State Zip Code Home Phone Number E-mail Address Please do NOT email me important news and updates. How would you prefer to be contacted? Home Phone Email Other Other Preference Borrower Employment Borrower Employment Status Employed Retired Other Time on Job Co-Borrower Information First Name Middle Initial Last Name Select Suffix I II III IV Jr. Sr. Suffix Home Address City Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey 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 State Zip Code Home Phone Number E-mail Address Please do NOT email me important news and updates. How would you prefer to be contacted? Home Phone Work Phone Email Other Other Preference co-borrower Employment co-borrower Employment Status Employed Retired Other Time on Job Endorsement I certify that all information provided by me herein, including attachments (s) is true, correct and complete. I authorize Kalamazoo County State Bank to contact me. Yes, I agree Type the numbers you see above: Submit
