Member FDIC | Equal Housing Lender
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|Inquirer's Name||Social Security No.||Contact Phone|
Each of the undersigned specifically represents to Lender and to Lender's actual or potential agents, brokers, processors, attorneys, insurers, servicers, successors and assigns and agrees and acknowledges that:
(1) the information provided in this request form is true and correct as of the date set forth opposite my signature and that any intentional or negligent misrepresentation of this information contained in this request form may result in civil liability, including monetary damages, to any person who may suffer any loss due to reliance upon any misrepresentation that I have made on this request form, and/or in criminal penalties including, but not limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Sec. 1001, et seq.;
(2) all statements made in this request form are made for the purpose of obtaining information only for a residential mortgage loan.