Quick Loan Application Date Email Address Req'd Loan Amount Requested Estimated Value of Property or Requested Purchase Price Applicant(s) Borrower Age SSN Co-Borrower Age SSN Address Years Phone City State Zip Employment Borrower Present Employer Gross Monthly Income Position Years Phone Co-Borrower Present Employer Gross Monthly Income Position Years Phone Other Income Borrower Income/Source Monthly Amount Co-Borrower Income/Source Monthly Amount Real Estate Loan Purpose: Purchase Refinance Refinance with cash out Other Property Address City State Zip 1st Mortgage Holder Monthly Payment Months Left 2nd Mortgage Holder Monthly Payment Months Left Assets Bank or Savings & Loan Approx. Balance Bank or Savings & Loan Approx. Balance Bank or Savings & Loan Approx. Balance Bank or Savings & Loan Approx. Balance The above information is correct to the best of my knowledge and I intend it to be relied upon for the purpose of the above application. By clicking on the "Submit Application" button below, I hereby authorize Fiztpatrick Real Estate to make whatever inquiries it considers necessary and appropriate concerning such information. By clicking on the "Submit Application" button below, I hereby authorize my credit references to provide information to Fitzpatrick Real Estate.