Estimated Close Date	Within 30 Days 30 - 60 Days 60 - 90 Days 90 - 120 Days 120+	Desired Interest Rate Type	-----Select One ----- Fixed Rate Adjustable Rate I Don't Know
Have you found a home?	Yes No	Do you have a real estate agent	Yes No
Do you have a signed contract to buy your home?	Yes No

Desired Loan Type	-------Select One ------- Refinance Refinance - Cash Out Home Improvement Debt Consolidation Home Equity Loan	Current Interest Rate Type	-----Select One ----- Fixed Rate Adjustable Rate I Don't Know
Additional Cash Needed	-----Select One ----- $0 $1 - $9,999 $10,000 - $14,999 $15,000 - $19,999 $20,000 - $24,999 $25,000 - $29,999 $30,000 - $34,999 $35,000 - $39,999 $40,000 - $44,999 $45,000 - $49,999 $50,000 - $54,999 $55,000 - $59,999 $60,000 - $64,999 $65,000 - $69,999 $70,000 - $74,999 $75,000 - $79,999 $80,000 - $84,999 $85,000 - $89,999 $90,000 - $94,999 $95,000 - $99,999 $100,000 - $104,999 $105,000 - $109,999 $110,000 - $114,999 $115,000 - $119,999 $120,000 - $124,999 $125,000 - $129,999 $130,000 - $134,999 $135,000 - $139,999 $140,000 - $144,999 $145,000 - $149,999 $150,000 - $154,999 $155,000 - $159,999 $160,000 - $164,999 $165,000 - $169,999 $170,000 - $174,999 $175,000 - $179,999 $180,000 - $184,999 $185,000 - $189,999 $190,000 - $194,999 $195,000 - $199,999 $200,000+	First Mortgage Interest Rate	-----Select One ----- 3.00 3.25 3.50 3.75 4.00 4.25 4.50 4.75 5.00 5.25 5.50 5.75 6.00 6.25 6.50 6.75 7.00 7.25 7.50 7.75 8.00 8.25 8.50 8.75 9.00 9.25 9.50 9.75 10.00 10.25 10.50 10.75 11
First Mortgage Balance	-----Select One ----- $0 $10,000 - $19,999 $20,000 - $29,999 $30,000 - $39,999 $40,000 - $49,999 $50,000 - $59,999 $60,000 - $69,999 $70,000 - $79,999 $80,000 - $89,999 $90,000 - $99,999 $100,000 - $109,999 $110,000 - $119,999 $120,000 - $129,999 $130,000 - $139,999 $140,000 - $149,999 $150,000 - $159,999 $160,000 - $169,999 $170,000 - $179,999 $180,000 - $189,999 $190,000 - $199,999 $200,000 - $209,999 $210,000 - $219,999 $220,000 - $229,999 $230,000 - $239,999 $240,000 - $249,999 $250,000 - $259,999 $260,000 - $269,999 $270,000 - $279,999 $280,000 - $289,999 $290,000 - $299,999 $300,000 - $309,999 $310,000 - $319,999 $320,000 - $329,999 $330,000 - $339,999 $340,000 - $349,999 $350,000 - $359,999 $360,000 - $369,999 $370,000 - $379,999 $380,000 - $389,999 $390,000 - $399,999 $400,000 - $419,999 $420,000 - $439,999 $440,000 - $459,999 $460,000 - $479,999 $480,000 - $499,999 $500,000 - $519,999 $520,000 - $539,999 $540,000 - $559,999 $560,000 - $579,999 $580,000 - $599,999 $600,000 - $619,999 $620,000 - $639,999 $640,000 - $659,999 $660,000 - $679,999 $680,000 - $699,999 $700,000 - $719,999 $720,000 - $739,999 $740,000 - $759,999 $760,000 - $779,999 $780,000 - $799,999 $800,000 - $819,999 $820,000 - $839,999 $840,000 - $859,999 $860,000 - $879,999 $880,000 - $899,999 $900,000 - $919,999 $920,000 - $939,999 $940,000 - $959,999 $960,000 - $979,999 $980,000 - $999,999 $1,000,000+	Credit Card Debt	-----Select One----- Below 10,000 10,000 - 15,000 15,000 - 20,000 20,000 - 25,000 25,000 - 30,000 30,000 - 35,000 35,000 - 40,000 40,000 - 45,000 45,000 - 50,000 50,000+

Name of Current Lender:		No.of mortgage payments you are behind :	---Select one--- 4 or more 3 2 1
First Mortgage Monthly Payment:		First Mortgage Interest Rate	-----Select One ----- 3.00 3.25 3.50 3.75 4.00 4.25 4.50 4.75 5.00 5.25 5.50 5.75 6.00 6.25 6.50 6.75 7.00 7.25 7.50 7.75 8.00 8.25 8.50 8.75 9.00 9.25 9.50 9.75 10.00 10.25 10.50 10.75 11
Current Interest Rate Type	-----Select One ----- Fixed Rate Adjustable Rate I Don't Know

Credit Card Debt	-----Select One----- $0 Less than $5,000 $5,000 - $9,999 $10,000 - $19,999 $20,000 - $29,999 $30,000 - $39,999 $40,000 - $49,999 $50,000 - $59,999 $60,000 - $69,999 $70,000 - $79,999 $80,000 - $89,999 $90,000 - $99,999 $100,000+	Payment Status	-----Select One ----- Current About to fall behind 31+ behind 61+ behind
First mortgage balance	-----Select One ----- $0 $10,000 - $19,999 $20,000 - $29,999 $30,000 - $39,999 $40,000 - $49,999 $50,000 - $59,999 $60,000 - $69,999 $70,000 - $79,999 $80,000 - $89,999 $90,000 - $99,999 $100,000 - $109,999 $110,000 - $119,999 $120,000 - $129,999 $130,000 - $139,999 $140,000 - $149,999 $150,000 - $159,999 $160,000 - $169,999 $170,000 - $179,999 $180,000 - $189,999 $190,000 - $199,999 $200,000 - $209,999 $210,000 - $219,999 $220,000 - $229,999 $230,000 - $239,999 $240,000 - $249,999 $250,000 - $259,999 $260,000 - $269,999 $270,000 - $279,999 $280,000 - $289,999 $290,000 - $299,999 $300,000 - $309,999 $310,000 - $319,999 $320,000 - $329,999 $330,000 - $339,999 $340,000 - $349,999 $350,000 - $359,999 $360,000 - $369,999 $370,000 - $379,999 $380,000 - $389,999 $390,000 - $399,999 $400,000 - $419,999 $420,000 - $439,999 $440,000 - $459,999 $460,000 - $479,999 $480,000 - $499,999 $500,000 - $519,999 $520,000 - $539,999 $540,000 - $559,999 $560,000 - $579,999 $580,000 - $599,999 $600,000 - $619,999 $620,000 - $639,999 $640,000 - $659,999 $660,000 - $679,999 $680,000 - $699,999 $700,000 - $719,999 $720,000 - $739,999 $740,000 - $759,999 $760,000 - $779,999 $780,000 - $799,999 $800,000 - $819,999 $820,000 - $839,999 $840,000 - $859,999 $860,000 - $879,999 $880,000 - $899,999 $900,000 - $919,999 $920,000 - $939,999 $940,000 - $959,999 $960,000 - $979,999 $980,000 - $999,999 $1,000,000+	First Mortgage Interest Rate	-----Select One ----- 3.00 3.25 3.50 3.75 4.00 4.25 4.50 4.75 5.00 5.25 5.50 5.75 6.00 6.25 6.50 6.75 7.00 7.25 7.50 7.75 8.00 8.25 8.50 8.75 9.00 9.25 9.50 9.75 10.00 10.25 10.50 10.75 11+

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