Borrower's Name: Married: Yes No Property Address: City: State: Zip: Phone Number: E-Mail: Best Time to Call: How did you hear about us?: Is this your primary residence: Yes No   My Credit History is: Excellent/Squeaky Clean Good, but a couple of lates OK. but I/We have had some problems Have had some major problems, but none in the last two years Interesting It should be good, but I really don't know   Original Loan Amount: Date of Loan: Approximate Current Balance: Second Mortgage Amount: Value of Property:   Type of Loan: Conventional FHA VA Year Fixed Adjustable Rate Graduated Payment   Interest Rate on loan: % Term of loan: Years Monthly Payment: Prepayment penalty: Yes No   Impounds: Taxes: Yes No Insurance: Yes No   Additional Information: :