Home Loan Information   Request Form Instructions: Use this form to request your mortgage information. Please fill out as much of the form as possible. When finished, click on 'Submit Application'. Your South Florida home-mortgage representative will contact you. A convenient day or evening phone number would be required. General Information: Borrower Co-Borrower Full Name Address City and State Country Zip or Post Code Home Phone Work Phone Best Contact Time E-mail Fax # (if avail) US-Resident? Employer Employer Phone Self-Employed ? Yes No Yes No Length of Employment Monthly Income Past Bankruptcy? YesNo Yes No  Credit History is: Excellent Good, but some lates Some problems Major credit problems Don't know Excellent Good, but some lates Some problems Major problems Don't know Loan Request Information: Amount Required:  Type of Loan: Home Purchase Loan Home Refinance Cash-out-Refinance Credit Line Home Equity Loan Home Construction Loan Construction-Permanent Other Mortgage Property Information: Property Street Address City, State Zip Code Estimated Property Value Probable Purchase Date Condominium?  Yes  No Intended Property Use Primary Residence Second/Vacation Investment Home Property Purchase Amount Existing Loan Information: Present Mortgage(s) Balance Held by Bank Monthly Payment First Second Other Other Creditors Amount Owed Monthly Payment Will be Paid Off? $ $ Yes No $ $ Yes No $ $ Yes No $ $ Yes No Any additional monthly debts and information - please describe: By submitting this on-line application, I/we authorize South Florida Residential Mortgage Services/South Florida Buyerside Realty, to check such things as my/our business or employment status and other provided information.