Pre-Qualification Form - Countryside Mortgage

Borrower

First Name*

Middle Initial

Last Name*

DOB Month*

DOB Day*

DOB Year*

Social Security Number

Email*

Cell Phone Number...*

Address*

City*

State*

Zip*

How Long At Current Address

Living Status at Address

Loan Officer

Loan Offiecer selectbox*

Income

Notice: Alimony, Child Support Or Separate Maintenance Income Need Not Be Revealed If The Borrower Or Co-Borrower Does Not Choose To Have It Considered For Repaying This loan.

Gross Monthly Income

Employment Section

Employment Status

Name Of Employer

How Many Years

How Many Months

Assets

Checking

Savings

Retirement Funds

Other Assets

Additional Real Estate Owned

Do You Own Additional Real Estate

How Many Properties

Additional Details

Marital Status

Do you pay child support or alimony

How Much Per Month

Is This a Purchase or Refinance

Are You a Veteran

How Many Dependents

Age of Dependent

Childcare Expenses Monthly

First Time Home Buyer

Co-Borrower

Click here if you have a Co-Borrower

Click here if you have a Co-Borrower

First Name*

Middle Initial

Last Name*

DOB Month*

DOB Day*

DOB Year*

Social Security Number

Email*

Cell Phone Number...*

Click Here If Address is Same as Above

Click Here If Address is Same as Above

Address*

City*

State*

Zip*

How Long At Current Address

Living Status at Address

Income

Notice: Alimony, Child Support Or Separate Maintenance Income Need Not Be Revealed If The Borrower Or Co-Borrower Does Not Choose To Have It Considered For Repaying This Loan.

Gross Monthly Income

Employment Section

Co Bro Employment Status

Co Bro Name of Employer

Co Bro How Many Years employee

Co Bro How Many Years self employee

Co Bro How Many Months employee

Co Bro How Many Months self employee

Assets

Co Bro Checking

Co Bro Savings

Co Bro Retirement Funds

Co Bro Other Assets

Additional Real Estate Owned

Co Bro Do You Own Additional Real Estate

Co Bro How Many Properties

Additional Details

Co bro Marital Status

Co Bro Do you pay child support or alimony

Co Bro How Much Per Month

Co Bro Are You a Veteran

How Did You Hear About Us?

How did you hear about us

Friend Name

Friend Cell Phone Number

RealtorName

Realtor Cell Phone Number

Builder Name

Builder Cell Phone Number

Authorization

Borrower Authorization Checkbox*

Borrower Signature

I understand that by submitting this online application, I am authorizing a credit check and to make whatever inquiries necessary in connection with this request.

Upload borrower digital signature

Click Here If You Want To Upload Digital Signature

Signature*

For easier signing please turn the phone sideways.

Borrower digital signature upload*

Accepted file types: jpg, png, jpeg, Max. file size: 3 MB.

Co-Borrower Signature Below

Co Borrower Authorization Checkbox

Check here if co-borrower is not present to sign the digitial signature.

Chk Co borrower upload digital signature

Click Here If You Want To Upload Digital Signature

Please Provide Your Co-Borrower Digital Signature:

Co Signature*

For easier signing please turn the phone sideways.

Co borrower digital signature

Accepted file types: jpg, png, jpeg, Max. file size: 3 MB.

Co-Borrower signature Email

Co-Borrower Cell Phone Number*

Info For Government

The following information is requested by the Federal Government for certain types of loans related to a dwelling in order to monitor the lender's compliance with equal credit opportunity, fair housing and home mortgage disclosure laws. You are not required to furnish this information, but are encouraged to do so. The law provides that a Lender may not discriminate either on the basis of this information, or on whether you choose to furnish it. If you furnish the information, please provide both ethnicity and race. For race, you may check more than one designation. If you do not furnish ethnicity, race, or sex, under Federal regulations, this lender is required to note the information on the basis of visual observation and surname if you have made this application in person. If you do not wish to furnish the information, please check the box below.

	Borrower	Co-Borrower
Government Monitoring
I do not wish to furnish this information
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Race
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Asian
White
Black or African American
Sex
Female
Male

Mortgage Form Application

Borrower

Loan Officer

Income

Employment Section

Assets

Additional Real Estate Owned

Additional Details

Co-Borrower

Income

Employment Section

Assets

Additional Real Estate Owned

Additional Details

How Did You Hear About Us?

Authorization

Info For Government