Mortgage Loan Pre‐Qualification

Important Information About Procedures For Opening a New Account

To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account.

What this means for you:

When you open an account, we will ask for your name, address, date of birth and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents and use third party identifiers such as chex systems and/or credit bureau reports.

Loan Information

Are you already working with a loan officer? Yes No

Loan Officers Name

Are you applying for joint credit? Yes No

What type of mortgage are you applying for? Conventional FHA/VA/USDA Land Other

Explain

Purpose of Loan Purchase Refinance Construction

Loan Amount Purchase Price Estimated Cost

Property Occupancy Primary Residence Second Home Investment Property

Borrower Information

First Name Middle Initial Last Name Suffix Social Security Number Birth Date Mother's Maiden Name Primary Phone Number Alternate Phone Number E-mail Address Please do NOT email me important news and updates.

Marital Status Unmarried Married Separated

Number of Dependents (Not Listed by Co-Borrower) List Dependents' Ages

Housing

Home Address City State Zip Code Mailing address is different than street address.

Mailing Address City State Zip Code

Do you own or rent this property? Own Rent Other

Explain Residency Start Date Rent First Mortgage Second Mortgage Hazard Insurance Property Taxes Mortgage Insurance Home Owners Association Dues

Have you lived here for two or more years? Yes No

Previous Home Address City State Zip Code

Did you own or rent this property? Own Rent Other

Explain Residency Start Date Monthly Mortgage or Rent Payment

Employment Information

Is the borrower employed? Employed Not Employed

Employment Start Date Position or Title Gross Monthly Income Name of Employer

Self-Employed Yes No

Employer's Address City State Zip Code Employer's Phone Number Years In Line Of Work

Have you worked here for more than two years? (No if unemployed) Yes No

Previous Employer

Employment Start Date Position or Title Gross Monthly Income Name of Employer

Self-Employed Yes No

Employer's Address City State Zip Code Employer's Phone Number Years In Line Of Work

Co-Borrower Information

First Name Middle Initial Last Name Suffix Social Security Number Birth Date Mother's Maiden Name Home Phone Number Cell Phone Number E-mail Address Please do NOT email me important news and updates.

Marital Status Unmarried Married Separated

Number of Dependents (Not Listed by Borrower) List Dependents' Ages

Housing

Housing information same as Borrower? Yes No

Home Address City State Zip Code Mailing address is different than street address.

Mailing Address City State Zip Code

Do you own or rent this property? Own Rent Other

Explain Residency Start Date Monthly Mortgage or Rent Payment

Have you lived here for two or more years? Yes No

Previous Home Address City State Zip Code

Did you own or rent this property? Own Rent Other

Explain Residency Start Date Monthly Mortgage or Rent Payment

Employment Information

Is the borrower employed? Employed Not Employed

Employment Start Date Position or Title Gross Monthly Income Name of Employer

Self-Employed Yes No

Employer's Address City State Zip Code Employer's Phone Number Years In Line Of Work

Have you worked here for more than two years? (No if unemployed) Yes No

Previous Employer

Employment Start Date Position or Title Gross Monthly Income Name of Employer

Self-Employed Yes No

Employer's Address City State Zip Code Employer's Phone Number Years In Line Of Work

Financial Information

Please note: Alimony, child support or separate maintenance income need not be revealed if the Borrower or Co-Borrower does not choose to have it considered for repaying this loan. Also self employed borrowers, or borrowers with commission or bonus compensation structures, may be required to provide additional documentation such as tax returns and financial statements. (before taxes)

Borrower's Gross Monthly Income

Monthly Salary & Wages Monthly Bonus Income Monthly Commission Income Monthly Retirement Income Other Monthly Income (if any) Income Type

Co-Borrower's Gross Monthly Income

Monthly Salary & Wages Monthly Bonus Income Monthly Commission Income Monthly Retirement Income Other Monthly Income (if any) Income Type

Checking or Savings

Please list all checking and savings accounts.

Account

Bank Name Account Number Account Balance

Stocks & Bonds

Description Total Value

Real Estate

Property

Property Address City State Zip Code Estimated Value Mortgage Balance Mortgage Payment Property Type Monthly Rental Income

Miscellaneous Assets

Vested Interest in Retirement Plan Net Worth of Business Owned

Automobiles

Make	Model	Year	Estimated Value
Make	Model	Year	Estimated Value

Other Assets

Description	Total Value
Description	Total Value

Current Monthly Payments (Liabilities)

Name of Company	Monthly Payment	Current Balance
Name of Company	Monthly Payment	Current Balance

Borrower Declarations

List any additional names under which credit has previously been received and indicate appropriate creditor name(s) and account number(s)

Alternate Name	Creditor Name	Account Number
Alternate Name	Creditor Name	Account Number

Are there any outstanding judgments against you? Yes No

Explain

Have you been declared bankrupt within the past 7 years? Yes No

Explain

Have you had property foreclosed upon or given title or deed in lieu thereof in the last 7 years? Yes No

Explain

Are you a party to a lawsuit? Yes No

Explain

Have you directly or indirectly been obligated on any loan which resulted in foreclosure, transfer or title in lieu of foreclosure, or judgment? (This would include such loans as home mortgage loans, SBA loans, home improvement loans, educational loans, manufactured (mobile) home loans, any mortgage, financial obligation, bond, or loan guarantee. If "Yes" provide details, including date, name and address of Lender, FHA or VA case number, if any, and reasons for the action.) Yes No

Explain

Are you presently delinquent or in default on any Federal debt or any other loan, mortgage, financial obligation, bond, or loan guarantee? If "Yes", give details as described in the preceding question. Yes No

Explain

Are you obligated to pay alimony, child support, or separate maintenance? Yes No

Explain

Is any part of the down payment borrowed? Yes No

Explain

Are you a co-maker or endorser on a note? Yes No

Explain

Are you a U.S. citizen? Yes No

Are you a permanent resident alien? Yes No

Explain

Do you intend to occupy the property as your primary residence? Yes No

Have you had an ownership interest in a property in the last three years? Yes No

What type of property did you own? How did you hold the title to the home?

Co-Borrower Declarations

List any additional names under which credit has previously been received and indicate appropriate creditor name(s) and account number(s)

Alternate Name	Creditor Name	Account Number
Alternate Name	Creditor Name	Account Number

Are there any outstanding judgments against you? Yes No

Explain

Have you been declared bankrupt within the past 7 years? Yes No

Explain

Have you had property foreclosed upon or given title or deed in lieu thereof in the last 7 years? Yes No

Explain

Are you a party to a lawsuit? Yes No

Explain

Are you obligated to pay alimony, child support, or separate maintenance? Yes No

Explain

Is any part of the down payment borrowed? Yes No

Explain

Are you a co-maker or endorser on a note? Yes No

Explain

Are you a U.S. citizen? Yes No

Are you a permanent resident alien? Yes No

Explain

Do you intend to occupy the property as your primary residence? Yes No

Have you had an ownership interest in a property in the last three years? Yes No

What type of property did you own? How did you hold the title to the home?

Acknowledgement & Agreement

Each of the undersigned specifically represents to Lender and to Lender's actual or potential agents, brokers, processors, attorneys, insurers, servicers, successors and assigns and agrees and acknowledges that: (1) the information provided is true and correct as of the date set forth opposite my signature and that any intentional or negligent misrepresentation of this information may result in civil liability, including monetary damages, to any person who may suffer any loss due to reliance upon any misrepresentation that I have made herein, and/or in criminal penalties including, but not limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Sec. 1001, et seq.; (2) the property will not be used for any illegal or prohibited purpose or use; (3) all statements made herein are for the purpose of obtaining a residential mortgage loan; (4) the property will be occupied as indicated herein; (5) the Lender, its servicers, successors or assigns may retain the original and/or an electronic record, whether or not the Loan is approved; (6) the Lender and its agents, brokers, insurers, servicers, successors and assigns may continuously rely on the information provided herein, and I am obligated to amend and/or supplement the information provided if any of the material facts that I have represented herein should change prior to closing of the Loan; (7) in the event that my payments on the Loan become delinquent, the Lender, its servicers, successors or assigns may, in addition to any other rights and remedies that it may have relating to such delinquency, report my name and account information to one or more consumer credit reporting agencies; (8) ownership of the Loan and/or administration of the Loan account may be transferred with such notice as may be required by law; (9) neither Lender nor its agents, brokers, insurers, servicers, successors or assigns has made any representation or warranty, express or implied, to me regarding the property or the condition or value of the property; and (10) my transmission of this information as an "electronic record" containing my "electronic signature," as those terms are defined in applicable federal and/or state laws (excluding audio and video recordings), or my facsimile transmission of this information containing a facsimile of my signature, shall be as effective, enforceable and valid as if a paper version were delivered containing my original written signature.

Acknowledgement.

Each of the undersigned hereby acknowledges that any owner of the Loan, its servicers, successors and assigns, may verify or reverify any information contained herein or obtain any information or data relating to the Loan, for any legitimate business purpose through any source, including a source named in this information or a consumer reporting agency.

I/We fully understand that it is a Federal crime punishable by fine or imprisonment, or both, to knowingly make any false statements concerning any of the above facts as applicable under the provisions of Title 18, United States Code, Section 1001, et seq.

Type your name in the box below to represent your electronic signature.

Borrower

Do you permit the lender to run a credit report based on information you provided? Yes No

Borrower's Signature Date

Co-Borrower

Do you permit the lender to run a credit report based on information you provided? Yes No

Co-Borrower's Signature Date

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