Quick Application Form

Quick Submission

Mortgage Broker Information

Are you a Mortgage Broker OR working WITH ONE?

Yes No

Mortgage Broker (Select or Enter Your Information)

Email Address

First Name

Last Name

Company Name

Mobile Phone Number

Are you a Loan Officer or working with one?

Yes No

Email Address

First Name

Last Name

Company Name

Phone Number

What kind of program are you looking for?

SBA Loan product

Additional Desired Loan programs

Where are you in the process?

Lead Source

Borrower Info

First Name

Middle Name

Last Name

Borrower Email

Please Wait...

Secondary Email

Home Phone

Cell Phone

Fax

Cell Carrier

Preferred Communication

Is there a Co-borrower?

Alt. Phone #

Work Phone #

Address

Unit #

City

State

Zip Code

County

Country

Length of time at the present property

Length Of Time At The Present Property Months

Rent or Own

Rent Per Month Current Address

Has the borrower resided at the present address for less than two years?

Yes No

Previous Address

Previous Unit #

Previous City

Previous State

Previous Zip Code

Previous Country

Length of time at the previous property

Length Of Time At The Previous Property Months

Rent or Own

Rent Per Month Previous Address

Mailing Address

Mailing Address same as Current Address?

Mailing Address

Mailing Address Unit#

Mailing City

Mailing State

Mailing Zip Code

Mailing Address Country

Alternate Names

Alternate Section 1

First Name

Personal Info

Date Of Birth

Place Of Birth

Social Security Number

Driver License State

Driver License Number

Driver License Issuance Date

Driver License Expiration Date

Marital Status?

Unmarried Married Separated

Date of Marriage

Date of Divorce (If applicable)

Maiden Name

Full name of Spouse if not on mortgage

Citizenship

U.S. Citizen Perm Resident Non-Perm Resident Foreign National

Did you ever serve, OR are currently serving IN the United States Armed Forces?

Yes No

Servicing member Info

Projected Expiration Date of Service/Tour

Ages Of Dependents

Number Of Dependents

Mid Fico Score

Equifax Score

Transunion Score

Experian Score

Credit Score Range

Authorization Status

Co-borrower Information

First Name

Last Name

Email Address

Please Wait...

Home Phone

Cell Phone

Fax

Mobile Service Provider

Same as borrowers address?

Address

City

State

Zip Code

Rent or Own

Is the Co-Borrower Guaranteeing the loan?

Yes No NA

Length of time at address

Has the borrower resided at the present address for less than two years?

Yes No

Previous Address

Previous City

Previous State

Previous Zip Code

Rent or Own

Mailing Address

Same as borrowers mailing address?

Mailing Address

Mailing City

Mailing State

Mailing Zip

Personal Info

Date Of Birth

Place Of Birth

Social Security Number

Driver License State

Driver License Number

Driver License Issuance Date

Driver License Expiration Date

Marital Status?

Unmarried Married Separated

Married to Borrower?

Yes No

Citizenship

U.S. Citizen Perm Resident Non-Perm Resident Foreign National

Equifax Score

Mid Fico Score

Transunion Score

Experian Score

Credit Score Range

Borrower Type/Entity Info

Borrower Type

Trust Type

Retirement Entity

General Business Info

Entity Name

Trade Name/DBA

Entity Type

Date Of Formation

Time in Business

State Of Formation

States Registered In

Federal Tax ID/EIN

Business License Number

Issuance Date

Expiration Date

State Issued

Other States Operating In

DBA Name(s)

Prior Business Name(s)

Organizational Ref #

Business Phone

Website Address

Business Address

Start Date at Location

Address

Address 2/Suite/Unit #

City

State

Zip Code

Is the billing address the same as above?

Billing Address

Billing City

Billing State

Billing Zip Code

Location

Urban Rural Suburban

Property Ownership

Value of Property?

Total Debt on Property?

Name of Lender(s)?

Landlord/Mortgage Contact Name

Landlord/Mortgage Phone

Rent/Mortgage Payment

Business Details

Business Type

# of employees currently

# of employees after loan

Business Category

Type of product or service sold

Naics Code

NAICS Code look up

Does your business sell a

Service Product

Is your Business

B2B B2C

Is your business home based?

Yes No

Do you take credit card payments?

Yes No

Terminal/ POS Make/Model

How many card processor banks do you have active?

Merchant Processing Bank Name(s)

Do you charge sales tax?

Yes No

How are employees paid?

Do you have more than one business location?

Yes No

How many locations?

Other Location Details & Addresses

Is the business a franchise?

Yes No

Name of Franchise

Point of Contact

Point of Contact Phone

Point of Contact E-mail

Website for Franchise

is your business seasonal?

Yes No

if Yes, what are the peak months?

Business Description

Do you have Business Reference(s)?

Yes No

Phone Name

Company

Fax

Business Financials

Average Monthly Credit Card Sales

Average Monthly Deposits

Annual Revenue

Annual Gross Profit

YTD-Net Business Income

Date of Operating Agreement

Gross Annual Revenues $

Gross Income Last Year

Net Income Last Year

Gross Income 2 years ago

Net Income 2 years Ago

Average Bank Balance

Has business ever filed for bankruptcy?

Yes No

Status of Business Bankruptcy

Recent NSFs

Does your business owe taxes for years prior to the current year?

Yes No

Estimated amount owed

Members/Officers (List all members with 20% ownership or more) |

Please add one child Member/Officer and click on the save button to continue adding more members/officers.

How many members/officers are there with 20%+ ownership?

Corporate Secretary Name

Notes

Sales Method

Retail Swiped

KEYED

ECOMM

MOTO

Fee Schedule

Visa/MasterCard/Discover/AXP Qualified Credit Card Discount Rate(for Tiered/Flat) %

Visa/MasterCard/Discover/AXP Qualified Credit Card Pass Thru I/C Plus

Qualified Check Card Discount Rate (for Tiered/Flat)

Qualified Check Card PassThru I/C Plus

Visa/MasterCard/Discover/AXP

Authorization Fee

Monthly Program Fee "Cash Discount"

Customer Service Fee

Monthly Minimum Fee

PIN Debit Transaction Fee

Batch Fee

Amex OPT Blue Qualified Rate

Amex OPT Blue Mid Qual

Amex OPT Blue Non Qual

Amex OPT Blue Pass Thru I/C Plus

Amex ESA #

AVS Transaction Fee

EBT Transaction Fee

EBT Account#

Amex Processing Fee

Other Fee

3 Tier Pricing Visa/MC/Disc/AXP Mid Qual

3 Tier Pricing Visa/MC/Disc/AXP Non Qual

Chargeback Fee

ACH Retrieval Fee

Equipment Info

Are you currently using a point of sale system?

Yes No

Software

Software Version

Does your Business have a Land Line?

Yes No

How will your new terminal connect to the internet?

Does your business location(s) have internet?

Yes No

Do you have WiFi?

Yes No

Do you know the password?

Yes No

What is your Wifi password?

Do you expect your EBT?

Yes No

What is your EBT number?

What would you like to have printed on the bottom of the receipt?

Is the equipment for a restraunt?

Yes No

Do you want Tips Added On?

Yes No

Do you want the customer to fill out Tip on Receipt or at cashier when they checkout only?

Suggested % #1

Suggested % #2

Suggested % #3

Do you want your Terminal to automatically Batch out? (Not recommended for restraunts. Once it batches out, unentered Tips will be lost).

Yes No

At What Time?

Shipping Address

Shipping City

Shipping State

Shipping Zip Code

Additional Guarantors

Are there any additional guarantors?

Yes No

First Name

Middle Name

Last Name

Phone #

Cell

SSN

Date Of Birth

Marital Status?

Address

City

State

Zip

Credit Score

Citizenship

U.S. Citizen Perm Resident Non-Perm Resident Foreign National

Guarantor Notes

General Guarantor Notes

HMDA - (Borrower)

Do you wish to furnish this information?

Yes No N/A

What is your Ethnicity:

Hispanic or Latino

Mexican, Puerto Rican, Cuban, Other Hispanic or Latino

Mexican Puerto Rican Cuban Other Hispanic or Latino

Print Origin For example: Argentinean, Colombian, Dominican, Nicaraguan,Salvadoran, Spaniard, and so on

Not Hispanic or Latino Not Disclosed

What is your Race:

American Indian or Alaska Native Asian

Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Other Asian

Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian

Print Race For example: Hmong, Laotian, Thai, Pakistani, Cambodian, and so on.

Black or African American Native Hawaiian or Other Pacific Islander

Native Hawaiian, Guamanian or Chamorro, Samoan, Other Pacific Islander

Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander

Print Race For example: Fijian, Tongan, and so on.

White Not Disclosed

Sex:

Male Female Not Disclosed

Veteran an option for veteran

Non-Veteran Veteran Service-Disabled Veteran Spouse of Veteran Not Disclosed

HMDA - (Co-Borrower)

Do you wish to furnish this information?

Yes No N/A

What is your Ethnicity:

Hispanic or Latino

Mexican, Puerto Rican, Cuban, Other Hispanic or Latino

Mexican Puerto Rican Cuban Other Hispanic or Latino

Print Origin For example: Argentinean, Colombian, Dominican, Nicaraguan,Salvadoran, Spaniard, and so on

Not Hispanic or Latino Not Disclosed

What is your Race:

American Indian or Alaska Native Asian

Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Other Asian

Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian

Print Race For example: Hmong, Laotian, Thai, Pakistani, Cambodian, and so on.

Black or African American Native Hawaiian or Other Pacific Islander

Native Hawaiian, Guamanian or Chamorro, Samoan, Other Pacific Islander

Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander

Print Race For example: Fijian, Tongan, and so on.

White Not Disclosed

Sex:

Male Female Not Disclosed

Veteran

Non-Veteran Veteran Service-Disabled Veteran Spouse of Veteran Not Disclosed

Borrower Background

U.S. Citizen?

Yes No

Origin

Visa Status

Has the borrower been declared bankrupt within the past 5 years?

Yes No

Status of Personal Bankruptcy

If Yes, identify the types of bankruptcy

Please provide filing date, current status, properties included, etc...

Are there any outstanding judgments against the borrower or entities where borrower holds 20% or more ownership?

Yes No

(If Yes, Provide explanation below.)

Are there any active lawsuits against the borrower or entities where borrower holds 20% or more ownership?

Yes No

(If Yes, Provide explanation below.)

Have you had or currently have any property tax liens?

Yes No

(If Yes, Provide explanation below.)

Has the borrower directly or indirectly been obligated on any loan which resulted in foreclosure, transfer of title in lieu of foreclosure, or judgement?

Yes No

Status of Foreclosure

(If Yes, Provide explanation below.)

Is the borrower presently delinquent or in any default on any Federal debt or any other loan, mortgage, financial obligation, bond, or loan guarantee

Yes No

(If Yes, Provide explanation below.)

Have you ever been convicted of a felony or other fraud related crimes?

Yes No

(If Yes, Provide explanation below.)

Are you in a Civil Union or a Domestic Partnership, or do you have a non-borrowing spouse, or are you a party to a Designated Beneficiary Agreement?

Yes No

(If Yes, Provide explanation below.)

Within the past 7 years, have you completed a pre-foreclosure sale, whereby the property was sold to a third party and the Lender agreed to accept less than the outstanding mortgage balance due?

Yes No

Have you had property foreclosed upon in the last 7 years?

Yes No

Have you previously had a short sale?

Yes No

When was the short sale?

Please explain the circumstances of the short sale

Background Explanation

What is the latest date & year for which federal tax returns have been filed? (e.g., if returns for 2023 have been filed, the answer would be 12/31/2023)

Are any returns currently being audited or contested?

Yes No

what years (s)

Have you drawn a will?

Yes No

Please furnish the name of the executor(s) and year will was drawn

Have you ever had a financial plan prepared for you?

Yes No

Is there a line of credit or unused credit facility at any other institution(s)?

Yes No

Please indicate where, how much, and name of banker

Do you anticipate any substantial inheritances?

Yes No

Please Explain

Co-borrower Background

U.S. Citizen?

Yes No

Origin

Visa Status

Has the borrower been declared bankrupt within the past 5 years?

Yes No

Please provide filing date, current status, properties included, etc...

Are there any outstanding judgments against the borrowers? (If Yes, Provide explanation below)

Yes No

(If Yes, Provide explanation below.)

Do you have any active lawsuits against you?

Yes No

(If Yes, Provide explanation below.)

Have you had or currently have any property tax liens?

Yes No

(If Yes, Provide explanation below.)

Has the borrower directly or indirectly been obligated on any loan which resulted in foreclosure, transfer of title in lieu of foreclosure, or judgement?

Yes No

(If Yes, Provide explanation below.)

Is the borrower presently delinquent or in any default on any Federal debt or any other loan, mortgage, financial obligation, bond, or loan guarantee

Yes No

(If Yes, Provide explanation below.)

Have you ever been convicted of a felony or other fraud related crimes?

Yes No

(If Yes, Provide explanation below.)

Are you in a Civil Union or a Domestic Partnership, or do you have a non-borrowing spouse, or are you a party to a Designated Beneficiary Agreement?

Yes No

(If Yes, Provide explanation below.)

Background Explanation

Borrower Experience

Does borrower have provable real estate investment experience?

Yes No

# of years of experience?

# of properties completed in last 36 months

Property Type
Purchase date

Purchase Price

Amount Financed

Rehab Budget

Holding Title As

Ownership %

Ownership Status

Exit Monthly Rent

Sale Price

Sale Date

Address
City
State
Zip
Unit/Suite #

Outcome/Profit

Upload HUD

Property Type
Purchase date

Purchase Price

Amount Financed

Rehab Budget

Holding Title As

Ownership %

Ownership Status

Exit Monthly Rent

Sale Price

Sale Date

Address
City
State
Zip
Unit/Suite #

Outcome/Profit

Upload HUD

Property Type
Purchase date

Purchase Price

Amount Financed

Rehab Budget

Holding Title As

Ownership %

Ownership Status

Exit Monthly Rent

Sale Price

Sale Date

Address
City
State
Zip
Unit/Suite #

Outcome/Profit

Upload HUD

Does borrower have construction experience?

Yes No

# of years experience?

# of properties completed in last 36 months

Property Type

Purchase date

Purchase Price

Amount Financed

Rehab Budget

Holding Title As

Ownership %

Ownership Status

Exit

Monthly Rent

Sale Price

Sale Date

Address

City

State

Zip

Unit/Suite #

Outcome/Profit

Upload HUD

Property Type

Purchase date

Purchase Price

Amount Financed

Rehab Budget

Holding Title As

Ownership %

Ownership Status

Exit

Monthly Rent

Sale Price

Sale Date

Address

City

State

Zip

Unit/Suite #

Outcome/Profit

Upload HUD

Property Type

Purchase date

Purchase Price

Amount Financed

Rehab Budget

Holding Title As

Ownership %

Ownership Status

Exit

Monthly Rent

Sale Price

Sale Date

Address

City

State

Zip

Unit/Suite #

Outcome/Profit

Upload HUD

Is borrower a builder/developer?

Yes No

Does borrower have a GC on staff?

Yes No

Owner-User / Owner-Occupied Properties: has the borrower been in business for at least two years?

Yes No

# of years experience in this line of business?

# of properties completed in last 36 months

Property Type

Purchase date

Purchase Price

Amount Financed

Rehab Budget

Holding Title As

Ownership %

Ownership Status

Exit

Monthly Rent

Sale Price

Sale Date

Address

City

State

Zip

Unit/Suite #

Outcome/Profit

Upload HUD

Property Type

Purchase date

Purchase Price

Amount Financed

Rehab Budget

Holding Title As

Ownership %

Ownership Status

Exit

Monthly Rent

Sale Price

Sale Date

Address

City

State

Zip

Unit/Suite #

Outcome/Profit

Upload HUD

Property Type

Purchase date

Purchase Price

Amount Financed

Rehab Budget

Holding Title As

Ownership %

Ownership Status

Exit

Monthly Rent

Sale Price

Sale Date

Address

City

State

Zip

Unit/Suite #

Outcome/Profit

Upload HUD

Does borrower have any projects currently in progress?

Yes No

How many?

Does borrower own investment properties?

Yes No

How many?

Is borrower a member of an investment club or group?

Yes No

Name of Group/Club?

Do you have any professional licenses?

Yes No

Select Professional license

License #

Are you a full time real estate investor?

Yes No

How much liquid assets does borrower currently have?

Primary investment strategy

Describe Overall Real Estate Investment Experience

Primary investment strategy Explain

Track Record

Typical Transactions

Amount of financing requested

Amount of financing requested To

Typical purchase price

Typical purchase price To

Typical construction costs

Typical construction costs To

Typical sale price

Typical sale price To

No. of construction draws per project

No. of construction draws per project To

Months from purchase date to first construction draw

Months from purchase date to first construction draw To

Months from purchase date until construction complete

Months from purchase date until construction complete To

Months from purchase date to sale date

Months from purchase date to sale date To

No. of such projects that you will do at time

No. of such projects that you will do at time To

In which geographic areas do you intend to focus on the next 12-24 months?

Co-borrower Experience

Does borrower have provable real estate investment experience?

Yes No NA

# of years of experience?

List 3 examples of past deals:

Outcome/Profit

Upload HUD

# of properties completed in last 36 months

Address

Outcome/Profit

Upload HUD

Address

Outcome/Profit

Upload HUD

Does borrower have construction experience?

Yes No NA

# of years experience?

List 3 examples of past deals:

Outcome/Profit

Upload HUD

# of properties completed in last 36 months

Address

Outcome/Profit

Upload HUD

Address

Outcome/Profit

Upload HUD

Owner-User / Owner-Occupied Properties: has the borrower been in business for at least two years?

Yes No NA

# of years experience in this line of business?

# of properties completed in last 36 months

List 3 examples of past deals:

Outcome/Profit

Upload HUD

Address

Outcome/Profit

Upload HUD

Address

Outcome/Profit

Upload HUD

Do you have any projects currently in progress?

Yes No NA

How many?

Does borrower own investment properties?

Yes No NA

How many?

Is borrower a member of an investment club or group?

Yes No NA

Name of Group/Club?

Do you have any professional licenses?

Yes No

Select Professional license

License #

Are you a full time real estate investor?

Yes No

How much in liquid reserves?

Primary investment strategy

Primary investment strategy Explain

SBA Questions

Purpose of the loan:

Payroll Rent/Mortgage Interest Utilities Other

Detailed Explanation

Is the Applicant (if an individual) or any individual owning 20% or more of the equity of the Applicant subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges are brought in any jurisdiction, or presently incarcerated, or on probation or parole?

Yes No

Detailed Explanation

Have you been arrested in the past six months for any criminal offense?

Yes No

Detailed Explanation

Within the last 5 years, for any felony, has the Applicant (if an individual) or any owner of the Applicant 1) been convicted; 2) pleaded guilty; 3) pleaded nolo contendere; 4) been placed on pretrial diversion; or 5) been placed on any form of parole or probation (including probation before judgement)?

Yes No

Detailed Explanation

Has an application for the loan you are applying for now ever been submitted to SBA or to a Certified Development Company or lender in connection with any SBA program?

Yes No

Detailed Explanation

Is the Applicant a franchise that is listed in the SBAs Franchise Directory?

Yes No

Detailed Explanation

Does the Small Business Applicant have any Affiliates?

Yes No

Detailed Explanation

Has the Small Business Applicant and/or its Affiliates ever filed for bankruptcy protection?

Yes No

Detailed Explanation

Is the Small Business Applicant and/or its Affiliates presently involved in any pending legal action?

Yes No

Detailed Explanation

Is the Applicant or any owner of the Applicant presently suspended, debarred, proposed for debarment, declared ineligible, voluntarily excluded from participation in this transaction by any Federal department or agency, or presently involved in any bankruptcy?

Yes No

Detailed Explanation

If you are at least a 50% or more owner of the applicant business, are you more than 60 days delinquent on any obligation to pay child support arising under an administrative order, court order, repayment agreement between the holder and a custodial parent, or repayment agreement between the holder and a state agency providing child support enforcement services? .

Yes No

Detailed Explanation

Has the Small Business Applicant and/or its Affiliates ever obtained a direct or guaranteed loan from SBA or any other Federal agency or been a guarantor on such a loan?

Yes No

Is any of the financing currently delinquent?

Yes No

Detailed Explanation

Did any of this financing ever default and cause a loss to the Government?

Yes No

Detailed Explanation

Are any of the Small Business Applicants products and/or services exported or is there a plan to begin exporting as a result of this loan?

Yes No

Provide the estimated total export sales this loan will support:

Is the Small Business Applicant using (or intending to use) a packager, broker, accountant, lawyer, etc. to assist in (a) preparing the loan application or any related materials and/or (b) referring the loan to the lender?

Yes No

Detailed Explanation

Are any of the Small Business Applicants revenues derived from gambling, loan packaging, or from the sale of products or services, or the presentation of any depiction, displays or live performances, of a prurient sexual nature?

Yes No

Detailed Explanation

No SBA employee, or the household member (see definition on page 1) of an SBA employee, is a sole proprietor, partner officer, director, or stockholder with a 10 percent or more interest, of the Applicant.

Yes No

Detailed Explanation

No former SBA employee, who has been separated from SBA for less than one year prior to the request for financial assistance, is an employee, owner, partner, attorney, agent, owner of stock, officer, director, creditor or debtor of the Applicant.

Yes No

Detailed Explanation

No member of Congress, or an appointed official or employee of the legislative or judicial branch of the Federal Government, is a sole proprietor, general partner, officer, director, or stockholder with a 10 percent or more interest, or household member of such individual, of the Applicant.

Yes No

Detailed Explanation

No Government employee having a grade of at least GS-13 or higher is a sole proprietor, general partner, officer, director, or stockholder with a 10 percent or more interest, or a household member of such individual, of the Applicant

Yes No

Detailed Explanation

No member or employee of a Small Business Advisory Council or a SCORE volunteer is a sole proprietor, general partner, officer, director, or stockholder with a 10 percent or more interest, or a household member of such individual, of the Applicant.

Yes No

Detailed Explanation

Have you, or any business you controlled, ever filed for bankruptcy protection?

Yes No

Detailed Explanation

Is the United States the principal place of residence for all employees of the Applicant included in the Applicants payroll calculation above?

Yes No

Detailed Explanation

Do any of your employees earn more than $100,000/year?

Yes No

If Yes, Did you calculate your estimated monthly payroll using the cap of 100,000 per employee?
Detailed Explanation

Has the Applicant, any owner of the Applicant, or any business owned or controlled by any of them, ever obtained a direct or guaranteed loan from SBA or any other Federal agency that is currently delinquent or has defaulted in the last 7 years and caused a loss to the government?

Yes No

Detailed Explanation

Are you, or any business you control, presently involved in any legal action (including divorce)?

Yes No

Detailed Explanation

Has the Business received an SBA Economic Injury Disaster Loan between January 31, 2020 and April 3, 2020?

Yes No

Loan Amount

Detailed Explanation

Yes No

Detailed Explanation

Other Business/Affiliate Information

Company Name

Tax Id/EIN #

Legal Owners/Title/Ownership %

# of employees

Years in Business

Has applied for SBA loans?

Yes No

Description

Add Other Business Info

How many W-2 Employees do you have?

How many W-2s did you issue for 2020?

When was your company started?

Did you operate under full or partial suspension due to government order?

No Partial Suspension Full Suspension

How your business was impacted during the partial or full shutdown

What quarters were you affected? (If not sure leave blank)

Please provide gross receipts of each quarter excluding any PPP funds if they are included as revenue

Q1 2019

Q2 2019

Q3 2019

Q4 2019

Q1 2020

Q2 2020

Q3 2020

Q4 2020

Q1 2021

Q2 2021

Q3 2021

Q4 2021

Did any of your vendors operate under full or partial suspension due to government order that affected your ability to do business?

No Partial Suspension Full Suspension Not Sure

How your business was impacted during the partial or full shutdown

What quarters were you affected due to vendor delays

Please provide gross receipts of each quarter excluding any PPP funds if they are included as revenue

Q1 2019

Q2 2019

Q3 2019

Q4 2019

Q1 2020

Q2 2020

Q3 2020

Q4 2020

Q1 2021

Q2 2021

Q3 2021

Q4 2021

In 2020, which quarters experienced losses of at least 50% relative to the same quarter in 2019? If not, sure please leave blank

In 2021, which quarters experienced losses of at least 20% relative to the same quarter in 2019? If not sure, please leave blank

If you did receive a PPP loan(s), what was the amount(s)?

Draw 1

Draw 2

If you received a PPP loan(s), did you receive PPP loan forgiveness?

Draw 1

Yes No

Draw 2

Yes No

If you did have PPP loan forgiveness, what was the forgiven amount(s)?

Draw 1

Draw 2

Who is your payroll service provider?

Have you already claimed any Employee Retention Credits?

Yes No

If Yes, which quarter(s) and with which company?

Are any employees that are family members or 50%+ owners? If so, please provide names

Have you started any other businesses since Feb 15th 2020 with annualized revenues of less than $1,000,000 and that has active W-2 employees?

Do you have any other existing businesses with active w-2 employees? If yes, please let business entity names and number of W-2 employees

Assets (Include Borrower + Co-borrower amounts if any)

Type

Estimated Value ($)

Amount Owed ($)

Cash

Checking Account(s)

Savings/Money Market/CDs

Net worth of business(es) owned

Accounts & Notes Receivable

Accounts & Notes Receivable Owed

Stocks/Bonds/Mutual Funds/ETFs

Stocks / Bonds Owed

Non-Marketable Securities

Non-Marketable Securities Owed

IRA / Keogh Accounts

IRA / Keogh Accounts Owed

401k / ESOP Accounts

401k / ESOP Accounts Owed

Life Insurance -- Cash Surrender Value Only

Life Insurance Owed

Total cash in bank accounts

Total value of retirement accounts

Availability under lines of credit

Line of Credit Owed

Primary Residence

Primary Residence Owed

Secondary Residences

Secondary Residences Owed

Other Real Estate

Other Real Estate Owed

Cars

Cars Owed

Other Personal Property

Other Owed

Other Assets

Notes Payable to Banks & Others

Installment Account(s)

Revolving Debt

Unpaid/Payable Taxes

Secured Notes Payable to this Bank

Unsecured Notes Payable to this Bank

Accounts Payable (including credit cards)

Margin Accounts

Other Liabilities Owed

Other Assets Details

Other Liability Details

Unpaid Taxes Details

Total:

$

Total Est. Value

- Total Amt Owed

= Total Net Worth

$

- $

= $

Gifts or Grants

Gifts Or Grants : 1

Asset Type

Deposited/Not Deposited

Yes No NA

Source

Cash Or Market Value

Add Gifts Or Grants Info

Contingent Liabilities

Contingent Liabilities 1

Type Of Liability

Name of Company/Creditor

Monthly Payment

Months left to Pay

Balance/Amount

Account No

Estimated Tax Liability if you were to sell your major assets?

Description

Add New Contingent Liabilities

Borrower Employment Information

Position or Title

Employment Type

Start Date

Nature of Employers Business

I have ownership share of less than 25% I have ownership share of 25% or more

Monthly Income/Loss $

How often are you paid?

Weekly Monthly Every 2 weeks Twice a month

Employer Information

Employer Name

Years at job

Employer Address

Employer City

Employer State

Employer Zip

Employer Country

Please explain if employment history is less than 2 years

Employer Phone

May we contact you at work?

Years employed in this line of work / profession

Additional Employment Information : 1

Is this job an additional or previous Job?

Name

Address of Employer

Employer City

Employer State

Employer Zip

Employer Country

Employment Type

I have ownership share of less than 25% I have ownership share of 25% or more

Monthly Income/Loss $

Employed From

Employed To

Yrs employed in this line of work / profession

Employed by a family member, property seller, real estate agent, or other party to the transaction?

Are you the business Owner or Self-Employed?

Monthly Income

Overtime

Commission/Bonus

Military Entitlements

Other

Income from other sources

Total Monthly Income from Other Sources

Position / Title / Type of Business

Employer Phone

Co-borrower Employment Information

Position or Title

Employment Type

Start Date

Nature of Employers Business

I have ownership share of less than 25% I have ownership share of 25% or more

Monthly Income/Loss $

How often are you paid?

Weekly Monthly Every 2 weeks Twice a month

Employer Information

Employer Name

Years at job

Employer Address

Employer City

Employer State

Employer Zip

Employer Phone

May we contact you at work?

Years employed in this line of work / profession

Additional Employment Information : 1

Name

Address of Employer

Employment Type

I have ownership share of less than 25% I have ownership share of 25% or more

Monthly Income/Loss $

Employed From

Employed To

Are you the business Owner or Self-Employed?

Monthly Income

Position / Title / Type of Business

Employer Phone

Borrower Monthly Income

Base Employment Income

Commission/Bonus

Military Entitlements

Overtime

Net Rental

Dividends / Interest

Capital Gains / (Losses)

Partnership / Subchapter S Income

Other

Other Income Description

Total Income

$ 0.00

(Borrower)

Co-borrower Monthly Income

Base Employment Income

Commission/Bonus

Overtime

Net Rental

Dividends / Interest

Capital Gains / (Losses)

Partnership / Subchapter S Income

Other

Other Income Description

$ 0.00

(Co-Borrower)

$ 0.00

(Borr + Cobor) 0.00

Borrower Monthly Expenses

Monthly Payment

Bal Owed

This loan

$

Real Estate Taxes

$

Insurances

$

Existing mortgages and Taxes/Insurance

Installment Loans

Credit Cards

Student Loans

Alimony/Child Support

Federal Income and Other Taxes

State Income and Other Taxes

Rental Payments, Co-op or Condo Maitenance

Mortgage Payments - Residential

Mortgage Payments - Investment

Property Taxes - Residential

Property Taxes - Investment

Interest & Principal Payments on Loans

Insurance

Investments (including tax shelters)

Tuition

Other Living Expenses

Medical Expenses

Other

Total Household Expenses

$

(Borrower)

Co-borrower Monthly Expenses

Monthly Payment

Bal Owed

Existing mortgages and Taxes/Insurance

Installment Loans

Credit Cards

Student Loans

Alimony/Child Support

Other

Total Household Expenses

$

(Co-Borrower)

$

(Borr + Cobor)

Liabilities

Alimony Payments

Child Support Payments

Separate Maintenance Payments

Job Related Expense (Child Care, union Dues, Etc).

Other Payments

Owed To

Partnerships

Partnerships 1

Type of Investment

Date of Initial Investment

Cost

Percent Owned

Current Market Value

Balance Due on Partnership: Holds, Cash, Call

Final Contribution Date

Add New Partnerships

Other New Mortgage Loans on the Property

Other New Mortgage Loans : 1

Creditor Name

Lien Type

Monthly Payment

Loan Amount/ Amount to be Drawn

Credit Limit

Add Other New Mortgage Loans

Loan Terms

Desired Closing Date

Rehab Amount

Funding Date

Desired Interest Rate Range

Borrower Occupancy

Lien Position

Transaction Type

Application Loan/Exit Plan

Loan Exit Plan (must choose Refi as this is a 12-month loan)

Account Executive Loan/Exit Plan Notes

Use Of Funds

Type of Purchase

PSA Closing Date

Doc Type

Maturity Date

Loan Term

Rate Lock Period

Rate Lock Date

Lock Expiration Date

Rate Lock Extension

Rate Lock Notes

Do you want to calculate buyer interest rate based on Monthly Payment?

Yes No

Buyer interest rate based on Monthly Payment

Amortization Type

Fixed Rate Adjustable Rate

Principal Repayment

Payment Frequency

Current Loan Balance

Total Loan Amount

Set Manual Payment

$ 0

Accrual Type

Monthly Escrows for Taxes & Insurance

Yes No

Annual Property Tax

Annual Insurance Policy Premium

Is this loan being cross collateralized?

Yes No

How many properties are collateralized? (including subj property)

Are the properties owned free and clear?

Yes No

Are these properties owned under the same entity as subject property?

Yes No

Resale Price

Resale Closing Date

Will the property need rehab or construction?

Yes No

Applicant confirmed all funds are for Business Purposes only

Acquisition / Purchase Price

Property Value (As-Is)

ARV

Is this ground up construction?

Yes No

Lot Status

Lot Purchase Price

Current Lot Market Value

Cost Spent

Original Purchase Price

Original Purchase Date

Construction Type

Construction Hard Cost

Construction Soft Cost

Contingency Type

Contingency %

Contingency Amount

Plans and Permits Status

Does project require re-zoning?

What is your anticipated hold time (months)?

Months

What is your anticipated plans and permit timeline (months)?

Months

What is your anticipated construction timeline (months)?

Months

Building Analysis Outstanding

Building Analysis Need

Building Analysis Due Date

maxAmtToPutDownClass Acquisition Down Payment $ commercialTdFieldsClass Down Payment %	transactionalTdFieldsClass Initial Loan Amount $
rehabConsClsClass LTV%	LOCTotalLoanAmt_dispClass Initial Loan Amount $
doesPropertyNeedRehabDispDivCLass1 Rehab/Construction Cost $ doesPropertyNeedRehabDispDivClass2 Rehab/Construction % Financed	doesPropertyNeedRehabDispDivClass3 Rehab/Construction Cost Financed $

propertyNeedRehabinitialTddispClass Initial Draw Amount $	payOffMortgage1_dispClass Pay-Off on Mortgage 1 $ Pay-Off on Mortgage 2 $ Pay Off Oustanding Taxes $ Closing Costs Financed $
Total Draws Funded $	propertyNeedRehabinitialTddispClass $
	CORTotalLoanAmt_disp Total Loan Amount $
	Total Cash Out $
	Total Loan Amount $
	Total Project Cost $
Additional Reserve Interest Additional Origination Interest	$

Total Loan Amount

Land Value

%

Acquisition LTV %

Market LTV %

%

$

%

Current Mortgage Refinance Info

Current Mortgage Refinance Info 1

Lien Number

Pay-Off Amount

VOM Status

Payoff Status

Original Purchase Date

Current Lender

Current Lender Full Address

Current Lender Email

Original Purchase Price

Maturity Date of Loan

Pre-Payment Penalty $

Pre-Payment Penalty %

Cost of Improvements made

Are taxes and insurance included in the payment?

Yes No

Monthly Payment

Current Rate

Current Loan Balance

Original Loan Balance

Add New Mortgage

Subject Property Details

1) Subject Property Details

Is this the main subject property?

Property Location

Subject Address

Subject Unit#

Subject City

Subject State

Subject Zip Code

Subject Country

County

Location

Urban Rural Suburban

Municipality

Parcel No

Legal Description

District

Section

Block

Lot

MSA

Property Characteristics

Subject Property Type

Condo Eligibility

Total Sq. Ft

Lot Size (acres)

Year Built

Description and Features

Adj. Sq Ft

Waterfront

Construction Type

Construction Method

Year Purchased:

Value Added View

Yes No

Type of View

Type Of Frontage

Other

No of rooms

Electrical: last permitted/inspected update

Plumbing: last permitted/inspected update

HVAC: last permitted/inspected update

Basement

Basement finished?

Garage

Rentable Sq. Ft.

Roof: last permitted/inspected update

# of buildings

Property Pool Indicator

Yes No

Future Property Type

Future Bedrooms

Future Bathrooms

Future # Half Baths

Is This Mid-Construction

Yes No

What percentage of construction is complete?

Stabilized Rate

# of units

Future # of Units

Assessed Property Value

# of parcels

Current # of ADU(s)

Future # of ADU(s)

Occupancy Rate %

Current Commercial Tenant Occupancy Rate %

Anchor Tenant Y/N?

Yes No

Anchor Tenant Name

What % is CRE

What % is resi

Property Class

# of Stories

Lease Type

Lease Validation

Other

How Is The Property Currently Leased?

Is This a Planned Unit Development

Yes No

PUD Name

Market Rents

Property Analysis

Allocated Loan Amount

Annual Hazard Insurance

Annual Flood Insurance

Total Hazard + Flood Insurance

Annual Property Tax

Property Tax Source

Annual HOA Fees

Annual Total Expenses

Purchase Price

Total Existing Lien Payoffs

Gross Operating Income

Net Operating Income

30-Year Amortization Payment

Interest-only Payment

PITIA

ITIA

Value Used For Metrics(Purchase or AIV)

Required Valuation Methods

Allocated LTP (Loan-To-Purchase)

Allocated LTV

Qualifying Allocated LTV

30-Yr AM DSCR

Property Details

Estimated Property Value

After Repair Value

Is Subject Property Listed for Sale?

Yes No

Property List Price

Property List Date

Is construction or rehab complete?

Yes No

Cost Spent?

Pay Off Lien Release

Purchase Price

Property LTV

Loan to purchase Price

Loan-To-After-Repair Value (LTARV)

Acquisition Date

Zillow value

Get Zillow Value

Price Per Door

URL link 1 to Property

URL link 2 to Property

Subject Present Occupancy

Occupancy Notes

Subject Property Condition

Tell us the current property condition along with the plan and timeline for the next 12-months

Year Last Renovated

Tax year

Annual Property Taxes

Property Tax Due Date

Past Due Property Taxes: $

Lien Release/Payoff Amt

MLS Number

Annual Insurance Premiums

How long will it take for rehab to complete?

In Months

Property Access

Who to contact for property access? Name

Lock Box Info

Phone:

Can we obtain interior access?

Yes No

Relationship

Rent Roll

Rent Roll 1

Tenant Name

Unit Type

Unit #

Sq Ft

Bedroom

Bath

Half Baths

Lease Start Date

Lease End Date

Date of Last Rent Increase

Lease Payment Frequency

Lease Extension End Date

Move in Date

Preliminary Estimated Rents

Preliminary Rent Source

Market Rents

120% Market Rents

Market Rent Source

Actual Rents

Lease Validation

Monthly Rent

Subsidized

Yes No

Vacant

Yes No

Section 8

Yes No

Comments

File Upload

Add New Rent Roll Entry

Property Flood Certificates

Property Flood Certificates 1

Is Building in a Special Hazard Zone

Flood Zone

Flood Certificate Company

Date of Determination

NFIP Map Number or Community Panel Number

NFIP Map Panel Effective/Revised Date

Flood Certificate Number

Notes

NFIP Non-Participating

Add New Property Flood Certificates Entry

Appraisers information

Appraiser 1

Appraiser First Name

Appraiser Last Name

Email *

Appraiser Company

Phone

As Is Value

Rehabbed Value

Monthly Rent

Job Types

Date Obtained

Appraisal Status

Requested Return Date

Rush Order

Yes No N/A

Order Date

Comments

Upload Appraisal

Appraisal Effective Date

Primary Appraisal ECOA Delivery Date

Appraisal Inspection Date

Expected Delivery Date

Expected Delivery Delay #

Supplemental Product Form Type 1

Effective Date 1

Supplemental Product ECOA Delivery Date 1

Supplemental Product Form Type 2

Effective Date 2

Supplemental Product ECOA Delivery Date 2

Supplemental Product Form Type 3

Effective Date 3

Supplemental Product ECOA Delivery Date 3

Add New Appraiser Entry

HOA information

is there a HOA?

Yes No

Are HOA fees paid current?

Yes No

Monthly HOA Fees

Delinquency Total?

Contact Name

HOA Company Name

Address

City

State

ZipCode

Contact Phone #

Fax #

Does HOA Allow Rentals

Yes No

Is AirBnb Allowed

Yes No

HOA applies to all properties

Yes No

Is Community 55+?

Yes No

Notes

Is there a Master/Secondary HOA/COA?

Yes No

Amount

Contact Name

HOA Company Name

Address

City

State

Zip Code

Notes

Subject Property Cash Flow (Annualized)

Income Info

Residential Gross Potential Income

Residential Gross Potential Income Residential Calculate from Rent Roll?

Vacancy

Residential Vacancy Rate

Commercial Gross Potential Income

Commercial Gross Potential Income Commercial Calculate from Rent Roll?

Commercial Vacancy

Commercial Vacancy Rate

Other Income (Laundry,Parking,Other)

Other Income Vacancy

Other Income Vacancy Rate

Tenant Contributions

Tenant Contributions Vacancy

Tenant Contributions Vacancy Rate

Effective Gross Income

$

Expense Info

Annual Property Tax

Annual Insurance Policy Premium

HOA Fees

Operating Expenses

Water / Sewer

Electricity

Gas

Repairs/Maintenance

Legal

Payroll

Misc.

Common Area Utilities

Elevator Maintenance

Replacement Reserves

Tenant Reimbursements

Management Expense

Net Operating Income

$

Cap Rate

%

Reserves

$ 0.00

Reserve Factor

Debt Service Ratio

0.00

Cash Available To Service Debt

$0.00

Debt Service Ratio - PITIA

0.00

Gross Annual Rent of Largest Tenant

VENDOR & EQUIPMENT INFORMATION

1 )

Vendor Phone

Vendor Contact

Equipment Type

Equipment Detailed Type

Vin or Serial Number

Year

Sale Price

New Or Used

New Used

Make

Model

Quantity

Mileage

Equipment Description

Pictures of Property

Select file to upload

Add Pictures Property

1st Lien Current Mortgage Scenario

Loan Type

Current Unpaid Principal Balance

Original Loan Amt

Loan Number

Notice of Acceleration

Loan Origination Date

Remaining Months

Months Behind (Manual Entry)

Last Payment Made

Days Behind

Transfer of Servicing Date

Original Lender

Current Lender/Servicer

Mortgage Type

Mortgage Investor/Owner

Monthly Payment Details

Monthly Taxes

Monthly Property Insurance

Flood Insurance

Priv. Monthly Mortg. Insurance

Total Monthly Payment

Past Due Interest

Out of Pocket Escrow Adv

Past Due Mtg. Ins

Past Due H.O.A

Late Fees (Not Included)

Rep Name & all other contact info....

Rep Name

Phone #

Fax #

Cell #

Address

City

State

Zip

E-mail

Notes

2nd Lien Current Mortgage Scenario

2nd lien Loan Type

Terms

Rate %

Current Unpaid Principal Balance

Original Loan Amt

Payment

Loan Number

Past Due Interest

Last Payment Made

Current Lender/Servicer

Months Behind (Manual Entry)

Days Behind

Original Lender

Mortgage Type

Mortgage Investor/Owner

Rep Name & all other contact info....

Rep Name

Phone #

Fax #

Cell #

Address

City

State

Zip

E-mail

Notes

Foreclosure / Default Info

Has the borrower been 30+ days late in the past 12 months ?

Yes No NA

Is the mortgage currently behind?

Yes No NA

Has the borrower received a notice of foreclosure or default by the bank, attorney, or trustee?

Yes No NA

Type / Select the date Notice of Default received

Has client received notice of summons?

Yes No NA

Type / Select the date Notice of summons received

Type / Select Sales Date if provided by bank/attorney/trustee

Trustee Sale #

Jurisdiction

Index #

Attorney Information

First Name

Last Name

Firm Name

Phone

Fax

Cell

Address

City

State

Zip

Trustee Information

First Name

Last Name

Firm Name

Phone

Fax

Cell

Address

City

State

Zip

Notes

Loan Workout Q & A

Do you want to keep the property?

Yes No NA

Have you applied for a loan modification?

Yes No NA

Date of application

Date of modification

Please provide all details

Has the borrower filed for bankruptcy?

Yes No NA

Is the borrower behind on plan payments?

Yes No NA

Filing Date

What is the Bankruptcy disposition status?

Bankruptcy Case number

Date discharged

Was the mortgage debt reaffirmed?

Yes No NA

Are the property(s) included in the bankruptcy?

Yes No NA

Is this home currently listed for sale?

Yes No NA

For how long?

For Sale by Owner?

Yes No NA

Listing Realtor Name

Real Estate Agency

Listing Phone

Listing Price

Listing Date

Has the borrower received an offer on the property?

Yes No NA

Date of offer

Amount of offer

Does the borrower have more than one property?

Yes No NA

How many properties?

How many mortgages?

Are the property taxes currently delinquent?

Yes No NA

Delinquent tax total?

Which year(s) are delinquent?

How many people live in the property?

How many are dependents live in the property?

How many vehicles are owned?

Is there a person not on the mortgage note who lives in the residence and contributes financially to the household?

Yes No NA

How many years has the borrower lived in the property?

Is the borrower a natural person (NOT an entity like corp, llc, trust, etc...) ?

Yes No NA

Is any borrower a service member?

Yes No NA

Has any borrower recently been deployed away from their principal residence or recently received a permanent change of station order?

Yes No NA

Is any borrower the surviving spouse of a deceased service member who was on active duty at the time of death?

Yes No NA

Answer YES, if you have been convicted within the last 10 years of any one of the following in connection with a mortgage or real estate transaction: (a) felony larceny, theft, fraud or forgery, (b) money laundering or (c) tax evasion.

Yes No NA

Additional Questions

Is there an accepted purchase agreement?

Yes No

Purchase Agreement Expiration date

Loan Guarantee

Success Fee Payment

50% 100%

Are property renovations planned?

Yes No

What is the budget/cost?

Loan Exit Plan (must choose Refi as this is a 12-month loan)

Loan Exit Plan Explanation

What is the projected rental income per month?

Expected timeline to exit this loan

Is the property subject to any additional liens, encumbrances, or restrictions (i.e. Property Assessed Clean Energy Program aka PACE)?

Yes No

Please explain

Is the subject property(ies) currently under construction?

Yes No

Are you adding square footage?

Yes No

How many additional square feet are you adding?

Improvements to be Completed

Renovation Timeframe (months)

Will there be a 2nd lien or borrowed money for down payment?

Yes No

Jr. Lien Holder Name

Secondary Financing Amount

(If Yes, Provide explanation.)

Do you have invoices to factor?

Yes No

Amount

Do you have a current loan/advance balance?

Yes No

Balance

Held With

Does the borrower intend to occupy the property as their primary residence?

Yes No

Have you had ownership interest in another property in the last 3 years?

Yes No

What type of property did you own?

How did you hold title to the property

Are you borrowing any money for this real estate transaction or obtaining any money from a nother party, such as the seller or realtor, that you have not disclosed on this loan application?

Yes No

If Yes, what is the amount of this money?

Purpose(s) of loan

Please Explain

Desired Funding Amount

Assumability

Yes - See Terms & Conditions No

Security Instrument

Do you own the land?

Yes No

Will borrower personally guarantee this loan?

Yes No

Is this Loan subject to a Balloon Payment?

Yes No

Use Of Funds

Does the co-borrower intend to occupy the property as their primary residence?

Yes No

Is there a prepayment penalty for paying in excess of 20% of the original or unpaid loan balance?

Yes No

Is this loan based on limited or no Documentation of your Income and/or Assets?

Yes No

Will this loan be made wholly or in part from broker controlled funds as defined in section 10241(J) of the Business and Professions code?

May Will Will Not

Do you have a family relationship or business affiliation with the seller of the property?

Yes No

Have you or will you be applying for a mortgage loan on another property (not the property securing this loan) on or before closing this transaction that is not disclosed on this loan application?

Yes No

Have you or will you be applying for any new credit (e.g. installment loan,credit card, etc) on or before closing this loan that is not disclosed on this application?

Yes No

Are there any known hazards or safety issues (mold, foundation, structural, etc.)?

Yes No

Are professional reports available outlining the issues and remediation?

Yes No

Is this transaction subject to short sale approval by an existing lender?

Yes No

Display Notes

Use of Proceeds

Any significant changes in the next 12 months?

Yes No

Please Describe

Title Info

Current Name on Title

New Name on Title

Recording #

Title Order Number

Title Ordered Date

Title Report Date

Title Received Date

Borrower Vesting Information

Title Report

Title Exceptions

Title Info : 1

Title Rep First Name

Title Rep Last Name

Title Company

E-mail

Phone #

Cell

Fax

Toll Free

Title Address

Title City

Title State

Title Zip

Title Notes

Add Title Info

Attorney Info

Attorney Info : 1

Attorney Name

Attorney Firm Name

Bar #

Attorney Phone

Attorney E-mail

Add Attorney Info

Escrow Info

Escrow Info : 1

Escrow Rep First Name

Escrow Rep Last Name

Company

E-mail

Phone #

Toll Free

Fax

Cell

Escrow #

Escrow Address

Escrow City

Escrow State

Escrow Zip

Add Escrow Info

General Contractor

First Name

Last Name

Company Name

License Number

Phone

Website

Cell Number

Address

City

State

Zip Code

Toll Free

Financial Advisor

Financial Advisor : 1

First Name

Last Name

Name Of Company

Phone

Address

City

State

Zip

Website

Financial Advisor Notes

Add Financial Advisor

Accountant Info

Accountant : 1

First Name

Last Name

Name Of Company

Phone

Address

City

State

Zip

Website

Notes

Add Accountant

Insurance Agent Info

Insurance Agent Info 1

Insurance Rep First Name

Insurance Rep Last Name

Name of Company

E-mail

Phone

Address

City

State

Zip

Website

Insurance Rep Notes

Add New Insurance Agent Info

Billing/Payment Information

Check

Checking ACT Bank Name:

Checking ACT Holder\'s Name on Account

Loan Servicer

Servicer Exception

Same as Mailing Address?

ACT Holders Address of Record with Bank

ACT Holders City

State

Zip

9 Digit Bank Routing Number

Checking ACT Number

Deposit Date

Account Holder Type

Account Type

Personal Checking Personal Savings Business Checking

Credit Card

Type of Card

Card #

Card Holders Name on Card

CVV #

Same as Mailing Address?

Card Holders Address

ACT Holders City:

State

Zip

Tell us more about the scenario, including the challanges, and what you are looking for in more detail, include all information from any previous email or phone conversations with us:

Terms And Conditions

By submitting this application, you acknowledge that everything is true and correct to the best of your knowledge.

By checking this box I agree to the terms and conditions. the Terms and Conditions *

Borrower

By checking this box I agree to the Terms and Conditions above

Name Of Borrower

Date (System Generated)

Name of Borrower Signing:

Signature

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Co Borrower

By checking this box I agree to the Terms and Conditions above

Name Of Co Borrower

Date (System Generated)

Name of Co-Borrower Signing:

Signature

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