Debra Wein-Simon
(561) 737-5300

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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):
Checking: $  Bank:
$  Bank:
Savings: $  Bank:
$  Bank:
Credit Union: $  Bank:
Stocks: $
Bonds: $
Life Insurance: $
 
Present Residence  (If Owned):
Market Value: $
Morg. Value: $
Lender:
 
 
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