Residential Loan Application

Loan Information Form

Instructions

Use this form to request mortgage information.
Please fill out as much of this form as possible.
When finished click on the send button.

A loan officer will contact you. A phone number is required.

How did you find this Web site?

Please enter the Web Address of the document that led you to this site:

General Information

	Borrower	Co-borrower (If different)
Full Name:
Address:
City, State, Zip
Home Phone:
Work Phone:
Best time to contact:
E-mail:
Social Security #:
Employers:
Employers' Phone Number:
Are you self employed ?	Yes No	Yes No
Length of Employment:
Gross Monthly Income:
Date of Birth:
My credit history is:	excellent good, but some lates some credit problems major credit problems don't know	excellent good, but some lates some credit problems major credit problems don't know

Loan Request

Amount Requested:
Type of loan:

Property Information

(This information needs to be filled out for property that is collateral for the loan)

Street Address:
City, State, Zip Code:
Estimated Present Value:
Year Purchased:
Original Price:
Type of Property:	Primary Second/Vacation Investment
Purchase Amount:

Loan Information

Mortgage Balances	Amount:	Held by:	Payment:
First:
Second:
Other:

Creditors	Amount Owed	Monthly Payment	Will you pay this off ?
	$	$	Yes No
	$	$	Yes No
	$	$	Yes No
	$	$	Yes No

Other monthly debts and information - please describe

By submitting this on-line application, I/We authorize Peachstate Financial Services to check such things as my/our credit, business and employment status and histories.