Prequalify

Borrower Information:

Borrower (Full Name):
Date of Birth:	(ex. dd/mm/yyyy)
Soc. Security #:
Residence Phone #:
Business Phone #:
Present Address:
City:
State/Province:
Zip Code/Postal Code:
E-mail Address
Years at Present Address:		Rent $	/month
	or	Own $

Previous Address:
City:
State/Province:
Zip Code/Postal Code:

Marital Status:	Married Separated Unmarried (including single, divorced, or widowed)

Occupation: (Position & Title)
# of years:
Place of Employment: (Name & Address)
Previous Employer: (Name & Address)

Co-Borrower Information:

Co-Borrower (Full Name):
Date of Birth:	(ex. dd/mm/yyyy)
Soc. Security #:
Residence Phone #:
Business Phone #:
Present Address:
City:
State/Province:
Zip Code/Postal Code:
E-mail Address
Years at Present Address:		Rent $	/month
	or	Own $

Previous Address:
City:
State/Province:
Zip Code/Postal Code:

Marital Status:	Married Separated Unmarried (including single, divorced, or widowed)

Occupation: (Position & Title)
# of years:
Place of Employment: (Name & Address)
Previous Employer: (Name & Address)

Gross Annual Income:

	Borrower	Co-Borrower
Self-Employed ?	Yes No	Yes No
Base Salary:	$	$
Overtime:	$	$
Bonuses:	$	$
Commissions:	$	$
Dividends:	$	$
Net Rental Income:	$	$
Other:	$	$

Total:	$	$

Do You Intend To Occupy This Property ? Yes No
Number of Children:
Ages:
Other Dependents:

Assets:

Other Assets (Specify):

Liabilities:

(List outstanding obligations including auto loans, mortgage payments,credit cards,
personal loans, and all other loans.)

Type	Creditor's Name	Unpaid Balance	Due Date	Monthly Payment
		$		$
		$		$
		$		$
	Total:	$		$

Additional Monthly Obligations:
Alimony:		$
Child Support:		$
Child Care:		$

Are There Any Judgements or Lawsuits Present?

Yes No

Amount:

Is Any Part of the Down Payment or Settlement Costs
Being Obtained From a Source Other Than From Assets
Listed Above?

Yes No

I hereby give my consent to have my credit report secured
from any credit reporting agency which you designate.

Yes No

TAMMY STARR

ERA Realty Pros

170 Flanders Rd, Niantic, CT 06357

Phone: 860-625-0354

Fax: 860-739-2314