Years in Area

Is this a Manufactured Home?

Mortgage Holder/Landlord

Telephone Number

Cost

Balance:

Current Value

Job Title

Length of Employment

Telephone Number

Address, City, State ZIP

Previous Employer/Business Name

Job Title

Length of Employment

Telephone Number

If yes, where obtained?

If yes, how much?

The following information is requested by the Federal Government for certain types of loans related to a dwellng 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 discriminate neither on the basis of this information, nor 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 choose not to furnish it, under Federal regulations, this Lender is required to note ethnicity, race and sex on the basis of visual observation or surname. If you do not wish to furnish the above information, please check the box below. (Lender must review the above material to assure that the disclosures satisfy all requirements to which the Lender is subject under applicable state law for the particular type of loan applied for.)

Select One Male Female

Select One Hispanic/Latino Non-Hispanic/Latino

Make Selection(s) American Indian/Alaska Native Asian Black/African American Native Hawaiin/Pacific Islander White/Caucasian