Tell Us About Your Loan Needs
What type of loan do you need?	Refinance Home Equity Purchase Home

Tell Us About Your Property
Where is the property located?	Property State ? Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Property area code
Home description	Single Family Multi Family Town House Condo (No mobile or manufactured homes)
Property use	Primary Residence Second or Vacation Home Investment Property
When are you likely to buy a home?	Time to Purchase ? Immediately 30 Days 60 Days 90 Days No Time Constraint
Have you found a home?	NO YES
Do you have a signed contract to buy your home?	NO YES
Do you have a real estate agent?	NO YES
Agent name
Agent phone
Agent company	(example: Prudential, Remax)
Tell Us About Your Loan
Estimated home value	Estimated Home Value ? 75,000 - 80,000 80,001 - 85,000 85,001 - 90,000 90,001 - 95,000 95,001 - 100,000 100,001 - 105,000 105,001 - 110,000 110,001 - 115,000 115,001 - 120,000 120,001 - 125,000 125,001 - 130,000 130,001 - 135,000 135,001 - 140,000 140,001 - 145,000 145,001 - 150,000 150,001 - 155,000 155,001 - 160,000 160,001 - 165,000 165,001 - 170,000 170,001 - 175,000 175,001 - 180,000 180,001 - 185,000 185,001 - 190,000 190,001 - 195,000 195,001 - 200,000 200,001 - 210,000 210,001 - 220,000 220,001 - 230,000 230,001 - 240,000 240,001 - 250,000 250,001 - 260,000 260,001 - 270,000 270,001 - 280,000 280,001 - 290,000 290,001 - 300,000 300,001 - 310,000 310,001 - 320,000 320,001 - 330,000 330,001 - 340,000 340,001 - 350,000 350,001 - 360,000 360,001 - 370,000 370,001 - 380,000 380,001 - 390,000 390,001 - 400,000 400,001 - 420,000 420,001 - 440,000 440,001 - 460,000 460,001 - 480,000 480,001 - 500,000 500,001 - 520,000 520,001 - 540,000 540,001 - 560,000 560,001 - 580,000 580,001 - 600,000 600,001 - 620,000 620,001 - 640,000 640,001 - 660,000 660,001 - 680,000 680,001 - 700,000 700,001 - 720,000 720,001 - 740,000 740,001 - 760,000 760,001 - 780,000 780,001 - 800,000 800,001 - 820,000 820,001 - 840,000 840,001 - 860,000 860,001 - 880,000 880,001 - 900,000 900,001 - 920,000 920,001 - 940,000 940,001 - 960,000 960,001 - 980,000 980,001 - 1,000,000 Over 1,000,000
Down payment amount	Down Payment Amount 0% 3% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%
Desired rate type	Fixed Rate Adjustable Rate I Don't Know

Tell Us About Your Personal Finances
Credit status	Excellent Good Fair Poor
Annual income	Income ? Less than 30,000 30,000 – 44,999 45,000 – 59,999 60,000 – 74,999 75,000 – 89,999 90,000 – 104,999 105,000 – 120,000 Over 120,000
Occupational status	Employed Self Employed Retired Not Employed
Have you ever declared bankruptcy?	No/Not in Past 7 Years 5 – 7 Years Ago 2 – 5 Years Ago 1 – 2 Years Ago Less Than 12 Months Ago
Monthly debt payments	Monthly Debt ? 0 - 249 250 - 499 500 - 749 750 - 1,000 Over 1,000 (do not include housing)
Are you a first time buyer?	NO YES

Your Contact Information
First name
Last name
Street address
City
State	Contact State ? Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip
Email
Primary phone
Secondary phone
Best contact time	Morning on Primary Afternoon on Primary Evening on Primary Morning on Secondary Afternoon on Secondary Evening on Secondary
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