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Registered Correspondent Full Name:

First Name (of Borrower):

Last Name (of Borrower):

Email (of Borrower):

Phone Number (of Borrower):

Address of Subject Property (If Applicable)

City

State

How much money is needed?

Property Type:

Loan Type:

Credit Score:

Transaction Type:

Condition of property?

Current Value of Property

Current Mortgage Owed

Desired Rate?

Property Tenancy Status

Property Occupancy Status

If the property is rented, how much is the rent?

Has a Notice of Default (NOD) been received?

Yes (Please explain how long ago in "Notes" field) No

Any Short-Sales in the last three years?

Yes (Please explain how long ago in "Notes" field) No

Any Foreclosures within the last five years?

Yes (Please explain how long ago in "Notes" field) No

Any Bankruptcy within the last five years?

Yes (Please explain how long ago and if it was discharged or dismissed in "Notes" field) No

Any Collections, Judgments or Liens? (Select all that apply)

Collections Judgments Liens No

Is your mortgage current?

Yes No

Notes