The Brian Smith Group

Contact and Financial Information for Refinance
Please Complete numbers 1-14 below.
 
1.
Co-borrower contact information
First Name:
Middle Name:
Last Name:
Work Phone:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

2.
Cell phone or any other number we can use to contact you
 

  • 350 characters left.
3.
Date of Birth
 

  • 50 characters left.
4.
Marital Status
Married
Seperated
Unmarried
5.
Number of family members (including yourself)
 

  • 50 characters left.
6.
Number of dependents
 

  • 50 characters left.
7.
Ages of dependents
 

  • 50 characters left.
8.
Years of school after high school
 

  • 50 characters left.
9.
Please answer the following questions.
 Yes No    
Do you pay or receive child support or alimony?    
Are you retired or on Social Security?    
Are you divorced?    
Are you self-employed?    
Are you a business owner?    
Do you have any rental property?    
Have you had a bankruptcy in the last seven years?    
Have you had a foreclosure or short sale in the last 5 years?    
Are you a veteran?    
10.
Do you know what your credit rating is?
Yes
No
  • Comment:

  • 500 characters left.
11.
Can we access a credit report for you?
Yes
No
12.
Name of your employer and start date.
 

  • 350 characters left.
13.
Years in profession
 

  • 50 characters left.
14.
Do you have any of the following assetts? If so, please comment on the names of the companies that you have these accounts with?
 Yes No    
Checking/Savings account    
401K    
Retirement    
Stocks/Bonds    
CD's/other    
  • Comment:

  • 500 characters left.