31333 West 13 Mile Road
Farmington Hills, MI 48334
Tel: (248) 539-3029
Fax: (248) 579-4553

NOTE: ALL FIELDS ARE REQUIRED EXCEPT WHERE NOT APPLICABLE
(ie, if never refinanced, no refinance fields need to be filled out, etc.)
Email Address: Phone Number: ()Ext: Best Time to Contact You: AMPM
Broker/Lender Info:
Broker/Lender Name:
Date:
L/O:
Email:
Processor: Email:
Address:
City: State: Zip:
Phone:
Fax: Cell:
Applicant(s) Information:
Applicant Name:
Co-Applicant:
Relationship of Applicants:
 Single Husband & Wife Other:
D.O.B: /
Residence Address:
City: State: Zip:
Subject Property (if different):
City: State: Zip:
Home Phone:
Cell Phone: Work Phone:
Purpose of Loan:
Purchase price of real estate only
Year:
$
Original finance amount:
 $
Inherited
Gift From:
n/a
Residential
Commercial
Opinion of Value:
City Assessor Value:
 $ Loan Officer: $
Homeowner:
 $
Appraised Value:
 $
Actual
 Anticipated
History of Refinances: Yes (complete below) n/a
Year:
Amount:
 $
Reason:
Year:
Amount:
 $
Reason:
Year:
Amount:
 $
Reason:
Are they or were they in Bankruptcy?
Yes No
Reason:
Delinquent on Existing Mortgage?
# of Days:
Reason:
Are they in Foreclosure?
Yes No
 Reason:
Have they applied anywhere else?
Yes No
Reason:
Fico Scores (reference only):
Occupancy
Owner Occupied
2nd Home
Vacant
Rental written lease Rental without written Other
Type
Brick
Wood
Vinyl
Block
Other
Style Ranch Colonial Bungalow Vacant Land Other
Lot Size:
ft xft
 or:
Acres
Home Sq. Ft.
Appearance:
Describe their Credit:
Describe their Home:
Monthly Gross Income Amounts:
W2:
Applicant:
$
Co-Applicant:
 $
Self:
Applicant:
$
Co-Applicant:
 $
Pension:
Applicant:
 $
Co-Applicant:
 $
SSI:
Applicant:
 $
Co-Applicant:
 $
Cash:
Applicant:
 $
Co-Applicant:
 $
Total:
 $

Rate:
Term:

NOTICE TO LOAN OFFICER: Co-Borrower Information must only be provided when the income and assets of a person other than the "borrower" (including borrowers spouse) will be used as a basis for loan qualification. Alimony, child support, public assistance or separate maintenance income need not be revealed if the borrower chooses not to have it considered for repaying the loan.

Please fax (248-579-4553) borrowers authorization along with 1003, good faith and credit report to the fax number provided. This is a submission form for an equity-based mortgage loan. This is NOT intended for the consumer. If you wish not to submit online, you may call us at 248-539-3029.
Use of Funds: (be specific)
Pay off Existing mortgages/leins:
1) $
2) $
3) $
4) $
Pay off Taxes:
$
Items to be paid* (specify each):
1) $
2) $
3) $
4) $
5) $
6) $
7) $
8) $
9) $
10) $
Total Fees & Costs:
$
Total Loan Amount:
$

*Any monies paid to third parties. Otherwise denote as "Cash Out."