A.  Property Information:

Choose One: Purchase Reduce Rate Debt Consolidation Reduce Payment Cash Out

 B.  Borrower's Information:

Borrower

Co-Borrower

If less than 2, please provide:

If less than 2 years, please provide:

Yes No

If yes, please complete the Co-Borrower Information.  Otherwise go to the next section.

 C.  Bank Information:

Bank Accounts

Account 1

Account 2

Stocks and Bonds

Borrower

Co-Borrower

Yes  No

Yes  No

Yes  No

Yes  No

3. Have you had property foreclosed upon or given title or deed in lieu thereof in the last 7 years?

Yes  No

Yes  No

4.  Are you a party to a lawsuit?

Yes  No

Yes  No

5.  Have you directly or indirectly been obligated on any loan  which resulted in foreclosure, transfer of 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) 

Yes  No

Yes  No

6.  Are you presently delinquent or in default on any Federal debt or any other loan, mortgage, financial obligation, bond, or loan guarantee?  

Yes  No

Yes  No

7.  Are you obligated to pay alimony, child support, or separate maintenance?

Yes  No

Yes  No

Yes  No

Yes  No

Yes  No

Yes  No

Yes  No

Yes  No

11.  Do you intend to occupy the property as your primary residence?

Yes  No

Yes  No

Yes  No

Yes  No

   (1) What type of property did you own?

Principal Residence Second Home Investment Property None

   (2) How did you hold the title to your home?

Soley Jointly with Spouse Jointly with Another Person None

The following information is requested by the Federal Government for certain types of loans related to a dwelling, in order to monitor the Lender’s compliance with equal credit opportunity, fair housing and home mortgage disclosure laws.  You are not required to furnish this information, but are encouraged to do so.  The law provides that a Lender may neither discriminate on the basis of this information, nor on whether you choose to furnish it.  However, if you choose not to furnish it, under Federal regulations this Lender is required to note race and sex on the basis of visual observation or surname.  If you do not wish to furnish the above information, please check the box below.    (Lender must review the above material to assure that the disclosures satisfy all requirements to which the Lender is subject under applicable state law for the particular type of loan applied for.)

Borrower

Co-Borrower

I do not with to furnish this information

I do not with to furnish this information

Choose One: Hispanic or Latino Not Hispanic or Latino Do not wish to furnish

Choose One: Hispanic or Latino Not Hispanic or Latino Do not wish to furnish

Choose One: Do not wish to furnish American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

Choose One: Do not wish to furnish American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

Choose One: Do not wish to furnish Female Male

Choose One: Do not wish to furnish Female Male

  Choose one: Ailene Banks Amy Cambron Bill Jackson Brian Smith Carrie Marlin Chris White David Reitz Don McKinzie Grady Hawley Jason Majors Julie McKinzie Mickey Cambron Munshi Rahman Thelma Williams No one

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