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Individual's Name

Maritial Status

Country

Address

Address

City

County

State

Zip Code

Do you own or rent your primary residence:*

Number of years at primary residence?

Mailling Address (If different from primary residence)

Primary Phone Number

Secoondary Phone Number

Email

Date of Birth

Social Security Number

Employment Information

SeltEmployed

Employer Name

Position & Title

Employer Address

DECLARATIONS / QUESTIONNAIRE		Borrower
Please check YES or NO for each of the following questions	Yes	No
Are there any outstanding judgments against you?
Have you been declared bankrupt within the last seven (7) years?
Have you or any other entity of which you were/are a principal been in foreclosure or had any property that was foreclosed upon?
Are you party to a lawsuit?
Are you currently delinquent on any federal debt or any other loan, mortgage, financial obligation, bond, or loan guarantee?
Have you ever been convicted of a felony?
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?
Are you a US citizen?
Are you a permanent resident alien?
Do you intend to occupy the property as your primary residence?

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