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Loan Amount Requested:
Purpose of Loan:

Please Tell Us About Yourself(s)

BORROWER

Borrower Name:
Street Address:
City State Zip:
Years At Current Address:
Social Security Number:
Home Phone:
Alternate Phone:
Date of Birth:
Declared Bankruptcy Ever:	Yes No
Bankruptcy Discharge Date:
Employer Name:
Employer Phone:
Position:
Years at Employer:
Monthly Income:

CO-BORROWER (CB)

(CB) Name:
(CB) Street Address:
(CB) City State Zip:
(CB) Years At Current Address:
(CB) Social Security Number:
(CB) Home Phone:
(CB) Alternate Phone:
(CB) Date of Birth:
(CB) Declared Bankruptcy Ever:	Yes No
(CB) Bankruptcy Discharge Date:
(CB) Employer Name:
(CB) Employer Phone:
(CB) Position:
(CB) Years at Employer:
(CB) Monthly Income:

Please Tell Us About Your Home

Date Purchased:
Purchase Price:
Date of Last Appraisal:
Value of Last Appraisal:
Current Value of Home:
Number of Bedrooms:
Number of Bathrooms:
Approx Square Footage:
Garage Type:
Number of Car Garage:
Type of Dwelling:
Monthly Payment:
Taxes and Insurance Included:	Yes No
Current Mortgage Company:
Current Mortgage Balance:
Interest Rate:
Comments:

4719 Common Vista Circle - Indianapolis, IN 46220

P: 317 362 0378 F: 317 362 0379