Uniform Residential Loan

Name

Mortgage Applied for


VA FHA Conventional FmHA Other


Purpose of Loan

Purchase Refinance
Borrower Information

Borrower's Name (include Jr. or Sr. if applicable)

Co-Borrower's Name ( include Jr. or Sr. if applicable)
Social Security Number
Home Phone
Age
Yrs. School
Social Security Number
Home Phone
Age
Yrs. School
Married
Separated
Unmarried

(include single, divorced, widowed)
Dependents
(not listed by Co-Borrower)
Number of

Ages
Married
Separated
Unmarried
(include single, divorced, widowed)

Dependents
(not listed by Borrower)
Number of
Ages

Present Address
Own Rent No. Years
Street
City
State ZIP
Present Address
Own Rent No. Years
Street
City
State ZIP
If residing at present address for less that two years, complete following:
Former Address
Own Rent No. Years
Street
City
State ZIP
Former Address
Own Rent No. Years
Street
City
State ZIP
Former Address
Own Rent No. Years
Street
City
State ZIP
Former Address
Own Rent No. Years
Street
City
State ZIP
Employment Information
Borrower
Name and Address of Employer
Self-Employed Yrs. on this Job Yrs. employed in this line of Work/Profession
Street
City
State ZIP
Position/Title/Type of Business
Business Phone (include area code)
Co-Borrower
Name and Address of Employer
Self-Employed Yrs. on this Job Yrs. employed in this line of Work/Profession
Street
City
State ZIP
Position/Title/Type of Business
Business Phone (include area code)
If employed in current position for less than two years or if currently employed in more than one position, complete the following:
Name and Address of Employer
Self-Employed Dates (from-to)
Monthly Income
$
Street
City
State ZIP
Position/Title/Type of Business
Business Phone (include area code)
Name and Address of Employer
Self-Employed Dates (from-to)
Monthly Income
$
Street
City
State ZIP
Position/Title/Type of Business
Business Phone (include area code)
Name and Address of Employer
Self-Employed Dates (from-to)
Monthly Income
$
Street
City
State ZIP
Position/Title/Type of Business
Business Phone (include area code)
Name and Address of Employer
Self-Employed Dates (from-to)
Monthly Income
$
Street
City
State ZIP
Position/Title/Type of Business
Business Phone (include area code)
Monthly Income and Combined Housing Expense Information
Gross Monthly Income
Borrower
Co-Borrower
Total
Base Empl. Income*
$
$
$
Overtime
$
$
$
Bonuses
$
$
$
Commissions
$
$
$
Dividends/Interest
$
$
$
Net Rental Income
$
$
$
Other
$
$
$
Total
$
$
$
* Self-employed
Combined Monthly Housing Expense
Present
Proposed
Rent
$
 
First Mortgage (P&I)
$
$
Other Financing (P&I)
$
$
Hazard Insurance
$
$
Real Estate Taxes
$
$
Mortgage Insurance
$
$
Homeowner Assn. Dues
$
$
Other:
$
$
Total
$
$
Assets
Description
Cash or Market Value
Cash Deposit toward Purchase held by:

$
List checking and savings accounts below
Name and Address of Bank, S&L or Credit Union

Account Number
$
Name and Address of Bank, S&L or Credit Union

Account Number
$
Name and Address of Bank, S&L or Credit Union

Account Number
$
Name and Address of Bank, S&L or Credit Union

Account Number
$
Stock & Bonds (Company name/number & description)

$

Life insurance net cash value

Face Amount $

$
Subtotal of Liquid Assets $
Real estate owned (enter market value from schedule of real estate owned) $
Vested interest in retirement fund $
Net worth of business(es) owned (attach financial statement) $
Automobiles owned (make and year)
$
Other Assets (itemize) $
Total Assets a.
$
Acknowledgment and Agreement

The undersigned specifically acknowledge(s) and agree(s) that: (1) the loan requested by this application will be secured by a first mortgage or deed of trust on the property described herein: (2) the property will not be used for any illegal or prohibited purpose or use; (3) all statements made in this application are made for the purpose of obtaining the loan indicated herein; (4) occupation of the property will be as indicated above; (5) verification or revivification of any information contained in the application may be made at any time by the Lender, its agents, successors and assigns, either directly of through a credit reporting agency, from any source named in this, and the original copy of this application will be retained by the Lender, even in the loan is not approved; (6) the Lender, its agents, successors and assigns will rely on the information contained in he application a I/we have a continuing obligation to amend and/or supplement the information provided in this application if any of the material facts which I/we have represented herein should change prior to closing; (7) in the event my/our payments on the loan indicated in this application become delinquent, the Lender, its agents, successors and assigns, may, in addition to all their other rights and remedies,report my/our and account information to a credit reporting agency; (8) ownership of the loan may be transferred to successor or assign of the Lender without notice to me and/or the administration of the loan account may be transferred to an agent, successor or assign of the Lender with prior notice to me; (9) the Lender, its agents, successors and assigns make no representations or warranties, express or implied, to the Borrower(s) regarding the property, the condition of the property, or the value of the property.

Certification: I/We certify that the information provided in this application is true and correct as of the date set forth opposite my/our names on this application and acknowledge my/our understanding that any intentional or negligent misrepresentation(s) of the information contained in this application may result in civil liability and/or criminal penalties including, but no limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Section 1001, et seq. and liability for monetary damages to the Lender, its agents, successors and assigns, insurers and any other person who may suffer any loss due to reliance upon any misrepresentation which I/we have made on this application.

Borrower Date Co-Borrower Date

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