Customer Questionnaire - Purchase
Borrower
Co-Borrower
Personal Data
Full name (First Middle Last)
Birthdate
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
Home Street Address
Home City
State
Zip
State
Zip
Current Rent or Mortgage
Mobile Phone
Home Phone
e-mail
How do you think your credit rating is?
select one
excellent
good
fair
poor
select one
excellent
good
fair
poor
What member of our team were you referred to?
select one
Randy Harrington
Ellen Ferguson
Robin Williams
Eric Redding
Who referred you to us?
Employment
Current Employer
Type of Employment (W-2, 1099, retired)
Duration with Current employer
Former Employer (if current is < 2 years)
Type of Employment (W-2, 1099, retired)
If less < 2 years, is it the same line of work?
yes
no
yes
no
Gross Income
YTD Average Monthly Income
Last Years Adjusted Gross Income
2 Years Ago Adjusted Gross Income
Other Documented Monthly Income
Debt
Car Payments (mthly)
School Loans (mthly)
Home Loans - all mortgage loans(mthly)
Credit Cards (minimum mthly)
Child/Spouse Support/ mth
Other Mthly Payments
Funds
Total Available for Purchase
Source or Location of Funds
Reserves (savings, retirement, etc.)
Loan
Conventional / FHA / VA
Primary, 2nd home, Investment
Targets
Total monthly house payment including taxes and insurance
Purchase Value
Percentage for down payment
Include Impound Account (taxes and insurance)
yes
no
yes
no
Properties
Do you have other property?
no
yes
# financed?
no
yes
# financed?
Will you be selling your residence for this purchase?
yes
no
yes
no
Legal
Any outstanding judgements?
no
yes
no
yes
Declared bankruptcy in the last 7 years?
no
yes
no
yes
Party to a lawsuit?
no
yes
no
yes
US Citizen?
yes
no
yes
no
Permanent Resident Alien?
no
yes
no
yes
Additional Information