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NUMERICA MORTGAGE, LLC
This is not a loan application and is used for pre-qualification purposes only
BORROWER 1:
NAME: __________________________________ DOB: ____________ SS#: _______-______-_________
FIRST MI LAST SUFFIX
PHONE # ( )_________________ CELL # ( )__________________ EMAIL: _________________
HAVE YOU EVER DECLARED BANCRUPTCY? ______ HAD A FORECLOSURE? _______ WHEN?_______
BORROWER 2:
NAME: _______________________________ DOB: _______________ SS#: ________-______-________
FIRST MI LAST SUFFIX
PHONE # ( )_______________ CELL # ( )__________________ EMAIL:__________________
HAVE YOU EVER DECLARED BANCRUPTCY? ____ HAD A FORECLOSURE? _____WHEN?__________
____MARRIED _____UNMARRIED (SINGLE, DIVORCED, WIDOWED) _____SEPARATED
CURRENT ADDRESS:
Borrower 1
_______________________________________________________________________________________
STREET CITY STATE ZIP
OWN ____ RENT ____ OTHER ____
HOW LONG AT CURRENT RESIDENCE _________ AMOUNT OF PAYMENT $____________
Borrower 2
_____________________________________________________________________________________
STREET CITY STATE ZIP
OWN ____ RENT ____ OTHER ____
HOW LONG AT CURRENT RESIDENCE _________ AMOUNT OF PAYMENT $______________
PRIOR ADDRESS IF LESS THAN 2 YEARS - ADDRESS AND DATES
Borrower 1
_____________________________________________________________________________________
PRIOR ADDRESS IF LESS THAN 2 YEARS - ADDRESS AND DATES
Borrower 2 ______________________________________________________________________________________
SUBJECT PROPERTY IF DIFFERENT FROM ABOVE
_______________________________________________________________________________________
YEAR HOME WAS ACQUIRED (REFI ONLY) ________________
PURPOSE FOR LOAN: ____PURCHASE ____REFINANCE ____CONSTRUCTION ____COMMERCIAL
TYPE: ____PRIMARY RESIDENCE ____SECONDARY RESIDENCE ____INVESTMENT PROPERTY
AMOUNT APPLYING FOR: $__________________
TYPE OF PROPERTY ________________________________ EST VALUE/SALES PRICE $______________
SFR/MH/CONDO/FARM/COMMERCIAL/ETC
SIZE OF LOT ____________________ (ACRES)
CURRENT EMPLOYER:
Borrower 1 SELF EMPLOYED _____ (yes/no) Borrower 2 SELF EMPLOYED ____(yes/no)
COMPANY/ BORROWER 1 ` COMPANY/ BORROWER 2
_________________________________ ______________________________________
_________________________________ _____________________________________
ADDRESS ADDRESS
______________________________________ ______________________________________
_________________________________ _______________________________________
OCCUPATION/ BORROWER 1 OCCUPATION/ BORROWER 2
PHONE # (______)________________ PHONE # (______)________________
HOW LONG __________ HOW LONG ___________
GROSS MONTHLY INCOME $______________ GROSS MONTHLY INCOME $________________
PRIOR EMPLOYMENT IF LESS THAN 2 YEARS:
Borrower 1
_______________________________________________________________________________________
Borrower 2
_______________________________________________________________________________________
OTHER INCOME: $ ______________ OTHER INCOME: $__________________
SOURCE OF INCOME: __________________ SOURCE OF INCOME: ___________________
DO YOU PAY/RECEIVE CHILD SUPPORT? ________ AMOUNT: $____________
ASSETS:
CHECKING/SAVINGS ACCT:
_________________________________________________________________________________
INSTITUTION /BALANCE
_________________________________________________________________________________
INSTITUTION /BALANCE
MONEY MARKET/IRA’S:
_________________________________________________________________________________
INSTITUTION BALANCE
_________________________________________________________________________________
REAL ESTATE OWNED:
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PROPERTY ADDRESS |
AMOUNT OF MORTGAGE |
MORTGAGE PAYMENTS |
GROSS RENTAL INCOME |
TAXES & INS |
TYPE OF PROPERTY |
|
|
$ |
$ |
$ |
$ |
|
|
|
$ |
$ |
$ |
$ |
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AUTHORIZATION FOR RELEASE OF INFORMATION
I/WE HEREBY AUTHORIZE THE RELEASE OF PERSONAL AND/OR FINANCIAL INFORMATION BY NUMERICA MORTGAGE, LLC AS SPECIFIED BELOW:
Ø EMPLOYMENT AND INCOME VERIFICATION
Ø CHECKING AND SAVINGS DEPOSIT VERIFICATION
Ø MORTGAGE LOAN BALANCES AND PAYMENT HISTORY
Ø CONSUMER CREDIT BALANCES AND PAYMENT HISTORY
Ø ANY OTHER PERTINENT PERSONAL AND/OR FINANCIAL INFORMATION
A PHOTOCOPY OF THIS AUTHORIZATION MAY BE DEEMED TO BE THE EQUIVALENT OF THE ORIGINAL.
BORROWER 1 SIGNATURE:_______________________________________________________
___________________ _________-________-__________ ______________
DATE SSN DOB
BORROWER 2 SIGNATURE:_________________________________________________________________
___________________ ________-__________- ________ ________________
DATE SSN DOB
NUMERICA MORTGAGE, LLC
1111 NE 25TH AVE, SUITE 104
OCALA, FL 34470
PH: (352) 867-7060
PLEASE FAX BACK TO E-FAX (352) 502-4775
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