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Purpose of Loan: Loan Amount Requested: $ Best time to call: AMPM Email:


Application Type: Individual Joint |   *Marital Status: Married Unmarried Separated |   *# Dependents:
Borrower Name:
Social Security #:
Date of Birth (MM/DD/YYYY):
Phone # with Area Code:
Co-Borrower Name:
Social Security #:
Date of Birth (MM/DD/YYYY):
Phone # with Area Code:
Please list any alternate phone numbers, including area codes, in which you can be reached:
Current Address:
City, State, Zip:
County:
How Long in Home:
YRS MTHS
Previous Address:
(If less than 2 years at current residence)
City, State, Zip:

County:

How Long in Home:
YRS MTHS



Current 1st Mortgage lender name:
Monthly Payment (PITI):
$		 Loan Balance:
$		 Purchase Price:
$		 Date Purchased (MM/DD/YYYY):
 Current Value:
$
Current 2nd Mtg / HELOC
(IF Applicable) lender name:

Monthly Payment: $		 Loan Balance:
$		 Has Borrower/Co-Borrower ever had a Bankruptcy or Foreclosure:
YES NO - If YES, list discharge date:


Borrower Employer:
 How Long:
YRS MTHS		 Work Phone # w/ Area Code:
Position:
 Salary
(Gross per month)
$		 1099
W-2
Co-Borrower Employer:
 How Long:
YRS MTHS		 Work Phone # w/ Area Code:
Position:
 Salary
(Gross per month)$		 1099
W-2
Other Income: You do not have to disclose income from Child Support, Alimony, or Separate Maintenance unless you want us to consider it for obtaining this loan:

Source:

Monthly Gross Amount:
$


How did you hear about us? Any particular Loan Officer?



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Homeowner Express Mortgage & Refinance is a DBA organization of Need A Refi Mortgage Corporation
6013 Cape Loop * Land O' Lakes, FL 34639
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