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Palestinian Territory, Occupied
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Thailand
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Venezuela
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Virgin Islands, U.s.
Wallis and Futuna
Western Sahara
Yemen
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Length of time at present address
Length Of Time At The Present Property Months
Rent or Own
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Own
Rent
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
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
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Delaware
District of Columbia
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Iowa
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Maryland
Massachusetts
Michigan
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Ohio
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Puerto Rico
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Previous Zip Code
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United States
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the Congo
Cook Islands
Costa Rica
Cote D Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic Peoples Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao Peoples Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, the Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.s.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Length of time at the previous property
Length Of Time At The Previous Property Months
Number of Years at Address ?
Rent or Own
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Own
Rent
Rent Per Month Previous Address
Mailing Address
Mailing Address same as Current Address?
Same as Property Address?
Mailing Address
Mailing Address Unit#
Mailing City
Mailing State
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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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Mailing Zip Code
Mailing Address Country
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United States
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the Congo
Cook Islands
Costa Rica
Cote D Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic Peoples Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao Peoples Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, the Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.s.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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Own
Rent
Alternate Names
Alternate Section
1
First Name
First Name
First Name
Personal Info
Date Of Birth
Place Of Birth
Social Security Number
Driver License State
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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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Driver License Number
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
Did you ever serve, OR are currently serving IN the United States Armed Forces?
Yes
No
Servicing member Info
Currently serving on active duty
Currently retired,discharged, or separated from service
Only period of service was as a non-activated member of the Reserve or National Guard
Surviving Spouse
Projected Expiration Date of Service/Tour
Ages Of Dependents
Number Of Dependents
Mid Fico Score
Equifax Score
Transunion Score
Experian Score
Credit Score Range
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720 +
680 - 719
620 - 679
600 - 619
580 - 599
580 or Below
Foreign National- No Score
Co-borrower Information
First Name
Last Name
Email Address
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Home Phone
Cell Phone
Fax
Mobile Service Provider
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AllTel
ATT
Cingular
Cricket
H20
Metro PCS
Boost Mobile
Nextel
Sprint PCS
Straight Talk
T-Mobile
Tracfone
US Cellular
Virgin Mobile
Verizon
Same as borrowers address?
Address
City
State
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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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Rent or Own
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Own
Rent
Is the Co-Borrower Guaranteeing the loan?
Yes
No
NA
Length of time at present address
Has the coborrower resided at the present address for less than two years?
Yes
No
Previous Address
Previous City
Previous State
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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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Previous Zip Code
Number of Years at Address ?
Rent or Own
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Own
Rent
- Select -
Own
Rent
Mailing Address
Same as borrowers mailing address?
Mailing Address
Mailing City
Mailing State
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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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Mailing Zip
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Own
Rent
Personal Info
Date Of Birth
Place Of Birth
Social Security Number
Driver License State
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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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
Equifax Score
Mid Fico Score
Transunion Score
Experian Score
Credit Score Range
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720 +
680 - 719
620 - 679
600 - 619
580 - 599
580 or Below
Foreign National- No Score
Borrower Type/Entity Info
Borrower Type
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Individual
Entity
Trust
Retirement Entity
Trust Type
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Revocable
Irrevocable
Retirement Entity
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Self-Directed IRA
Self-Directed 401K
IRA LLC
General Business Info
Entity Name
Trade Name/DBA
Entity Type
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Sole Proprietorship
Limited Partnership
General Partnership
LLC
Corp
S-Corp
Self Employed-1099 Contractor
501 (c)(3) Nonprofit
501 (c)(19) Veterans Org
Tribal Business
Trust
Joint Venture
Estate
Other
Date Of Formation
Time in Business
Less than 3 Months
3-6 Months
6-12 Months
1-2 Years
2-3 Years
3-5 years
5+ years
State Of Formation
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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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
States Registered In
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Federal Tax ID/EIN
Business License Number
Issuance Date
Expiration Date
State Issued
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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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other States Operating In
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
- Select -
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Is the billing address the same as above?
Billing Address
Billing City
Billing State
-Select-
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Billing Zip Code
Location
Urban
Rural
Suburban
Property Ownership
- Select -
Own
Rent
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
- Select -
Mobile & E-Commerce
Retail
Home Improvement
Food & Beverage
Travel and Tourism
Transportation
Meetings and Events
Education
B2B
Healthcare
Government
Non-Profit
Entertainment
Lodging
Legal
Salon & Spas
Professional Services
Other
# of employees currently
# of employees after loan
Business Category
- Select -
Agriculture,Forestry,Fishing
Construction
Manufacturing
Transportation & Public Utilities
Whole Sale Trade
Retail Trade
Finance Insurance Real Estate
Services
Public Administration
Utilities
Transportation and Warehousing
Professional, Scientific,Tech Services
Educational Services
Health Care and Social Assistance
Arts,Entertainment,Recreation
Restaurant,Internet,Mail Order/Telephone Order
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?
- Select -
W-2
1099
W-2 & 1099
Cash
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
1
)
Phone Name
Company
Fax
Email
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
Still Active
Discharged- 1 month
Discharged- 1-3 months
Discharged- 3-6 months
Discharged- 6-12 months
Discharged-1 year
Discharged- 2 years
Discharged- 3 years
Discharged- 5 years
Discharged-7+ years
Recent NSFs
0
1
2
3
4
5
6
7
8
9
10+
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.)
Same as Borrower/Applicant Info Above
Name
Title
% of Ownership
%
Annual Salary/Compensation
Address
Phone
Cell
SSN
DOB
Credit Score
Email
Marital Status
Unmarried
Married
Separated
Date of Marriage
Date of Divorce(If applicable)
Maiden Name
Full name of Spouse if not on mortgage
Drivers License State
- Select -
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers License
Member TIN
Personal Guarantee for this loan
Yes
No
Authorized signer for making loans
Yes
No
Citizenship
U.S. Citizen
Perm Resident
Non-Perm Resident
Name
Title
% of Ownership
%
Annual Salary/Compensation
Address
Phone
Cell
SSN
DOB
Credit Score
Email
Marital Status
Unmarried
Married
Separated
Date of Marriage
Date of Divorce(If applicable)
Maiden Name
Full name of Spouse if not on mortgage
Drivers License State
- Select -
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers License
Member TIN
Personal Guarantee for this loan
Yes
No
Authorized signer for making loans
Yes
No
Citizenship
U.S. Citizen
Perm Resident
Non-Perm Resident
Name
Title
% of Ownership
%
Annual Salary/Compensation
Address
Phone
Cell
SSN
DOB
Credit Score
Email
Marital Status
Unmarried
Married
Separated
Date of Marriage
Date of Divorce(If applicable)
Maiden Name
Full name of Spouse if not on mortgage
Drivers License State
- Select -
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers License
Member TIN
Personal Guarantee for this loan
Yes
No
Authorized signer for making loans
Yes
No
Citizenship
U.S. Citizen
Perm Resident
Non-Perm Resident
Name
Title
% of Ownership
%
Annual Salary/Compensation
Address
Phone
Cell
SSN
DOB
Credit Score
Email
Marital Status
Unmarried
Married
Separated
Date of Marriage
Date of Divorce(If applicable)
Maiden Name
Full name of Spouse if not on mortgage
Drivers License State
- Select -
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers License
Member TIN
Personal Guarantee for this loan
Yes
No
Authorized signer for making loans
Yes
No
Citizenship
U.S. Citizen
Perm Resident
Non-Perm Resident
Name
Title
% of Ownership
%
Annual Salary/Compensation
Address
Phone
Cell
SSN
DOB
Credit Score
Email
Marital Status
Unmarried
Married
Separated
Date of Marriage
Date of Divorce(If applicable)
Maiden Name
Full name of Spouse if not on mortgage
Drivers License State
- Select -
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers License
Member TIN
Personal Guarantee for this loan
Yes
No
Authorized signer for making loans
Yes
No
Citizenship
U.S. Citizen
Perm Resident
Non-Perm Resident
Name
Title
% of Ownership
%
Annual Salary/Compensation
Address
Phone
Cell
SSN
DOB
Credit Score
Email
Marital Status
Unmarried
Married
Separated
Date of Marriage
Date of Divorce(If applicable)
Maiden Name
Full name of Spouse if not on mortgage
Drivers License State
- Select -
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers License
Member TIN
Personal Guarantee for this loan
Yes
No
Authorized signer for making loans
Yes
No
Citizenship
U.S. Citizen
Perm Resident
Non-Perm Resident
Name
Title
% of Ownership
%
Annual Salary/Compensation
Address
Phone
Cell
SSN
DOB
Credit Score
Email
Marital Status
Unmarried
Married
Separated
Date of Marriage
Date of Divorce(If applicable)
Maiden Name
Full name of Spouse if not on mortgage
Drivers License State
- Select -
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers License
Member TIN
Personal Guarantee for this loan
Yes
No
Authorized signer for making loans
Yes
No
Citizenship
U.S. Citizen
Perm Resident
Non-Perm Resident
Name
Title
% of Ownership
%
Annual Salary/Compensation
Address
Phone
Cell
SSN
DOB
Credit Score
Email
Marital Status
Unmarried
Married
Separated
Date of Marriage
Date of Divorce(If applicable)
Maiden Name
Full name of Spouse if not on mortgage
Drivers License State
- Select -
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers License
Member TIN
Personal Guarantee for this loan
Yes
No
Authorized signer for making loans
Yes
No
Citizenship
U.S. Citizen
Perm Resident
Non-Perm Resident
Name
Title
% of Ownership
%
Annual Salary/Compensation
Address
Phone
Cell
SSN
DOB
Credit Score
Email
Marital Status
Unmarried
Married
Separated
Date of Marriage
Date of Divorce(If applicable)
Maiden Name
Full name of Spouse if not on mortgage
Drivers License State
- Select -
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers License
Member TIN
Personal Guarantee for this loan
Yes
No
Authorized signer for making loans
Yes
No
Citizenship
U.S. Citizen
Perm Resident
Non-Perm Resident
Name
Title
% of Ownership
%
Annual Salary/Compensation
Address
Phone
Cell
SSN
DOB
Credit Score
Email
Marital Status
Unmarried
Married
Separated
Date of Marriage
Date of Divorce(If applicable)
Maiden Name
Full name of Spouse if not on mortgage
Drivers License State
- Select -
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Drivers License
Member TIN
Personal Guarantee for this loan
Yes
No
Authorized signer for making loans
Yes
No
Citizenship
U.S. Citizen
Perm Resident
Non-Perm Resident
Add More Members/Officers Info
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?
--select--
WiFi
Ethernet
Telephone Land Line
Mobile Unit with Built in Cellular
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?
--select--
On Receipt
At 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
- Select -
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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?
-Select -
Single
Married
An Entity
Divorced
Widowed
Address
City
State
- Select -
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Email
Credit Score
Citizenship
U.S. Citizen
Perm Resident
Non-Perm Resident
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
Is the borrower a U.S. Citizen?
Yes
No
Origin
Visa Status
Has the borrower been declared bankrupt within the past 7 years?
Yes
No
Status of Personal Bankruptcy
Still Active
Within 1 month
1-3 months
3-6 months
6-12 months
1 year
2 years
3 years
4 years
5 years
7+ years
If Yes, identify the types of bankruptcy
Chapter 7
Chapter 11
Chapter 12
Chapter 13
Please provide filing date, current status, properties included, etc...
Are there any outstanding judgments against the borrowers?
Yes
No
(If Yes, Provide explanation below.)
Does the borrower have any active lawsuits against them?
Yes
No
(If Yes, Provide explanation below.)
Does the borrower have any property tax liens or have they had any property tax liens in the past?
Yes
No
(If Yes, Provide explanation below.)
Has the borrower been directly or indirectly obligated on any loan which resulted in foreclosure, transfer of title in lieu of foreclosure, or judgement?
Yes
No
Status of Foreclosure
Still Active
Within 1 month
1-3 months
3-6 months
6-12 months
1 year
2 years
3 years
4 years
5 years
7+ years
(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.)
Has the borrower ever been convicted of a felony or other fraud related crime?
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
Income tax returns filed through
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
Are you a U.S. Citizen?
Yes
No
Origin
Visa Status
Has the borrower been declared bankrupt within the past 7 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 Fix & Flip or Buy & Hold experience?
Yes
No
# of years of experience?
# of properties completed in last 36 months
Property Type
- Select -
Single Family
Condo
Duplex
3 Units
4 Units
Multi-Family 5+
Mixed Use
Commercial
Purchase date
Purchase Price
Amount Financed
Rehab Budget
Holding Title As
Ownership %
Ownership Status
- Select -
Owned
Sold
Exit
- Select -
In progess-To Be rented
In Progress- To Be Sold
Rented
Sold
Monthly Rent
Sale Price
Sale Date
Address
City
State
;
- Select -
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Unit/Suite #
Outcome/Profit
Upload HUD
Property Type
- Select -
Single Family
Condo
Duplex
3 Units
4 Units
Multi-Family 5+
Mixed Use
Commercial
Purchase date
Purchase Price
Amount Financed
Rehab Budget
Holding Title As
Ownership %
Ownership Status
- Select -
Owned
Sold
Exit
- Select -
In progess-To Be rented
In Progress- To Be Sold
Rented
Sold
Monthly Rent
Sale Price
Sale Date
Address
City
State
;
- Select -
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Unit/Suite #
Outcome/Profit
Upload HUD
Property Type
- Select -
Single Family
Condo
Duplex
3 Units
4 Units
Multi-Family 5+
Mixed Use
Commercial
Purchase date
Purchase Price
Amount Financed