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Member FDIC | Equal Housing Lender
Privacy Statement

Quick Mortgage Loan Request Form
Submitter Information (Required)
First Name
Last Name
Resolve the errors marked in red before submitting again.

Privacy Policy:
Our privacy policy protects the privacy of your personal-identifying information that you provide us online.

Security Notice:
ONLY fill out this loan request form on-line if you are using a browser, with the latest security enhancements. If you do not have the latest version, download it now. This form is NOT cached (saved in your computer's memory) when you QUIT your browser.

Complete this form on-line and click "Submit". Upon receipt we will send you the proper disclosures. We will also contact you to discuss your request within three business days. To safeguard your privacy, please QUIT your browser and restart it again after submitting this form. Our Mortgage Request Form is for personal loans and is NOT intended for Business use.

Amount $No. of Months

Subject Property Address
Details of Transaction Purchase Price $
Purpose of Loan:
Property will be:
Borrower's NameSocial Security No.Contact PhoneDate of Birth

Present Address
Present Address
No. Years
Name & Address of Employer
Co-Borrower's NameSocial Security No.Home Phone (area code) Date of Birth

Co-Borrower Present Address
Present Address
No. Years
Name & Address of Employer
Gross Monthly Income

Acknowledgement and Agreement

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) the loan requested pursuant to this request form (the "Loan") will be secured by a mortgage or deed of trust on the property described herein;

(3) the property will not be used for any illegal or prohibited purpose or use;

(4) all statements made in this request form are made for the purpose of obtaining a residential mortgage loan;

(5) the property will be occupied as indicated herein;

(6) any owner or servicer of the Loan may verify or reverify any information contained in the request form from any source named in this request form, and Lender, its successors or assigns may retain the original and/or an electronic record of this request form, even if the Loan is not approved;

(7) the Lender and its agents, brokers, insurers, servicers, successors and assigns may continuously rely on the information contained in the request form, and I am obligated to amend and/or supplement the information provided in this request form if any of the material facts that I have represented herein should change prior to closing of the Loan;

(8) in the event that my payments on the Loan become delinquent, the owner or servicer of the Loan may, in addition to any other rights and remedies that it may have relating to such delinquency, report my name and account information to one or more consumer credit reporting agencies;

(9) ownership of the Loan and/or administration of the Loan account may be transferred with such notice as may be required by law;

(10) neither Lender nor its agents, brokers, insurers, servicers, successors or assigns has made any representation or warranty, express or implied, to me regarding the property or the condition or value of the property; and

(11) my transmission of this request form as an "electronic record" containing my "electronic signature," as those terms are defined in applicable federal and/or state laws (excluding audio and video recordings), or my facsimile transmission of this request form containing a facscimile of my signature, shall be as effective, enforceable and valid as if a paper version of this request form were delivered containing my original written signature.

Borrower's NameDateCo-Borrower's NameDate

To be completed and submitted by Borrowers

I understand that you will retain this form whether or not it is approved. You are authorized to check my/our credit and employment history and to answer questions about your credit experience with me/us.