Please provide the following contact information (*red text indicates required information):

Name
Address
Address (cont.)
City
State	Alabama Alaska Arizona Arkasas California Colorado Connecticut Delaware 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 Washington D.C. West Virginia Wisconsin Wyoming
Zip Code
Primary Phone
Alt. Phone
Cell Phone
FAX
E-mail

What type of loan do you currently have? Please Choose One: VA 30 Yr. Fixed VA 15 Yr. Fixed Conventional 30 Yr. Fixed Conventional 15 Yr. Fixed Conventional Adjustable Rate Mortgage (ARM) Other

If Other, please specify:

If you have a VA Loan, did you use your certificate of eligibility to secure the loan? Yes No

What is your current interest rate?

What month and year did you originally purchase your home?

When did you last refinance your home loan?

Did you refinance to another VA loan? Yes No

How long do you see yourself staying in your home? 6 months 1 year 2 to 5 years 5 to 10 years More than 10 years

What is your combined monthly escrow amount?

What amount of your escrow is for taxes?

Number of 30+ days late payments that have posted to your account in the last 12 months:

Have you ever filed Bankruptcy? Yes No

If yes:
What month and year did you file?
            When was it discharged?
            What Chapter was filed?

Do you have any 2nd mortgages, home equity lines of credit, home improvement loans and /or liens against your home? Yes No

If yes:
Name of Company:
Amount of Loan:
Month and Year Acquired:
Any other Mortgages? Yes No

Other Comments/Questions: