Home Equity Form
1.What type of property do you want to refinance?*	- Select - Single Family Home Condominium Townhouse Mobile Other
2.What is the zip code for the property?*
3.What is the estimated property value?*	- Select - $100,000 - $124,999 $125,000 - $149,999 $150,000 - $174,999 $175,000 - $199,999 $200,000 - $224,999 $225,000 - $249,999 $250,000 - $299,999 $300,000 - $349,999 $350,000 - $399,999 $400,000 - $449,999 $450,000 - $499,999 $500,000 - $549,999 $550,000 - $599,999 $600,000 - $699,999 $700,000 - $799,999 $800,000 - $899,999 $900,000 - $1,000,000 $1,000,000 - $1,500,000 $2,000,000 - $2,500,000 $3,000,000 - $3,500,000 $4,000,000 - $4,500,000 $5,000,000 Or More --------------------------------- Under $100,000
4.What is the first mortgage balance on the property?*
5.What is the first mortgage interest rate?*	%
6.What is your monthly payment?*
7.What is your rate type?*	- Select - Fixed Adjustable Both Not Sure
8.Are there additional mortgages on the property?*	Yes No
If yes, what is the balance of the additional mortgage?*
If yes, what is your monthly payment?*
9.What type of loan do you want?*	- Select - New/Second Mortgage Line of Credit Not Sure
10.What rate type do you want?*	- Select - Fixed Variable Not Sure
11.How much additional cash do you want to borrow?*
12. Are you currently working with a lender?*	Yes No
13. When do you anticipate closing?*	- Select - 30 60 90 120+ Days
14. What's your time frame for choosing an lender?*	- Select - Less than 1 Month 1 - 2 Months 2 - 3 Months 3 - 6 Months More than 6 Months
15. How is your credit?*	- Select - Excellent Good Fair Poor

Employment Information

1.What is your occupation?* - Select - Computers --Graphics --Operator/Technician --Programmer Engineering --Aerospace --Chemical --Civil --Electrical --Mechanical --Nuclear --Other Construction --Contractor --Electrician --Installer --Mechanic --Painter --Plumber --Welder Education --Administration --College Professor --Professional Instructor --Teacher Healthcare --Administration --Dentist/Dental Technician --Lab Technician --Nurse/Paramedic --Pharmacist --Physician/Surgeon --Psychiatrist/Psychologist/Social Worker --Hospitality/Recreation/Travel --Airline Employee --Amusement Parks/Recreation Centers --Driving --Hotel Services --Restaurant Services --Travel Agent Manufacturing --Assembly --Machine Operator --Maintenance --Printing Professional --Accounting --Architecture --Art/ Photography --Entertainment/Performing --Financial Services --Insurance --Interior Design --Journalism --Law/Legal Services --Marketing & Sales --Membership Organizations --Real Estate --Sports/Fitness/Nutrition Private Sector --Child Care --Cleaning Services --Homemaker --Landscaping/Gardening --Personal Assistant Public Service --Civil Service --Economic Administration --Environmental Administration --Executive Legislative --Fire Fighter --Government Employee --Human Resources --International Affairs --Justice, Public Order and Safety --Military Officer --National Security --Police Department --Postal Service --Public Transportation --Social Worker Retail --Auto Dealer/Service Center --Consumer Services/Sales --Management --Merchandising --Product Sales --Security Other-Not Listed Retired Self Employed Student Unemployed Veteran 2.What is your current employment status?* - Select - Full Time Part Time In Transition Retired Home Maker Student Other 3.How long have you been at your present job?* - Years - 0 Year 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 + Years - Months - 0 Month 1 Month 2 Months 3 Months 4 Months 5 Months 6 Months 7 Months 8 Months 9 Months 10 Months 11 Months 12 Months 4. Are you self-employed?* Yes No 5. What is your annual income?*   (Includes salary, commissions, bonuses and the annual income of any members of your household who will be applying for the loan with you.) 6. What do your bills total each month?* 7. Have you filed for bankruptcy in the past seven years?* Yes No 8. Do you currently have any tax liens or  judgments against you and your property?* Yes No Comments and concerns about your new insurance policy.                                           Personal Information First Name: Last Name: Email Address: Address: City: 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 Zip Code: Primary Number: Secondary Number: How did you hear from us: Google Yahoo MSN Other Search Engine Yellow Pages TV Adds Radio Adds Mailing Real Estate Agent Loan Officer Insurance Agent Attorney Accountant Friend or Family Other Indicate the person who referred you or reference number, if applicable: Additional Information: I would like to receive special offers.   We want to give you the best possible results. Please be sure to fill in all the fields marked with an asterisk.*

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