(* = mandatory)

* 1. Purchase or Refinance
       Select Purchase Refinance

* 2. What year did you purchase your home.
       Select 195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009

* 3. Purchase Price
      

* 4. Down Payment
      

* 5. Current Market Value
      

* 6. Overall Condition of the home
      

* 7. How much do you owe on your mortgage(s)?
      

  8. What is the current rate on your first mortgage?

       Select 4-5% 5-6% 6-7% 7-8% 8-9% 9-10% 10+

  9. How many credit cards or installment loans do you have?

       Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20+

  10.What’s the average interest rate on those items?

       Select 4-5% 5-6% 6-7% 7-8% 8-9% 9-10% 10-11% 11-12% 12-13% 13-14% 14-15% 15-16% 16-17% 17-18% 18-19% 19-20% 20+

  11. How much do you send out monthly in minimum payments on these items?

       Select $100-$500 $500-$1000 $1000-$1500 $1500-$2000 $2000+

  12. How many credit cards are maxed out or currently past due?

       Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20+

  13. Are you able to pay your credit cards off monthly?
       Yes     No

  14. Do you receive call at home and work from collection agencies about          past due or unpaid items currently?

       Yes     No

  15. Do you have any home improvements that need immediate attention? But         you do not have the available funds to complete them?

       Yes     No

  16. Is there anything wrong with the property that would make it not sellable?

       Yes     No

  17. Do you have 6 months worth of reserve money in case you or your         spouse is out of work for an extended period of time?

       Yes     No

  18. Is your car or cars dependable and safe for you or your family to drive in?

       Yes     No

(* = mandatory)
(** = Providing your Social Security number gives Citside Mortgage permission to pull credit.)