REFINANCE REQUEST Florida county where is property located? Please hold down Ctrl button to make multiple selections! SELECT Pinellas Pasco Hernando Other How much additional cash do you want to borrow? When was property purchased? SELECT January February March April May June July August September October November December SELECT 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 Before 1983 What type of property do you own? Please hold down Ctrl button to make multiple selections! SELECT Primary Residence Single Family Primary Condo Primary Townhome Primary Multipule Family Dwelling Second Home Condo Second Home Town Home Second Home Mobile Home Second/Vacation Mobile Home Primary Single Family Second Home Multi Family Dwelling Investment Condo Investment Mobile Home Investment Townhome Investment Multiple Family Dwelling Estimate your Property's current value? i.e. $150,000 What is your first mortgage loan balance? Your current mortgage term is: SELECT 30 Year Fixed 30 Year Adjustable 15 Year Fixed 15 Year Adjustable OTHER What is your current monthly payment? What is your current interest rate? Please indicate if you have a Second Mortgage: NO YES What is the current balance and how much is your monthly payment? Annual Income Household Income (GROSS INCOME). Monthly Income SELECT Excellent Some Problems Major Problems Please select your Credit History as: Did you Foreclose or File for Bankruptcy in the last 7 years? SELECT NO Last Year 2 Years Ago 3 Years Ago 4 Years Ago 5 Years Ago 6 Years Ago 7 Years Ago FIRST NAME                                      LAST NAME YOUR NAME: YOUR E-MAIL ADDRESS: YOUR ADDRESS: (include Street Address, City, State & Zip Code) How long have you been in your current job? SELECT Less than 6 mos. 6 to 12 mos. 1 to 2 years More than 2 years Retired Are you self-employed? NO YES Phone Numbers of Work and Home: (Include area code and extension, if applicable)