Mortgage Prequalification Application | Easy as 1-2-3 Personal Information Applicant * Date of Birth * Social Security Number * Co-Applicant Co-Applicant DOB Co-Applicant SSN Primary Phone * Alternate Phone Current Address * Apt # City * State * select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Monthly Payment * How Long * Landlord / Mortgage Company Name * Phone * If presiding at present address for less than two years, please complete the following Previous Address Apt # Rent / Own Rent Own City State select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Monthly Payment How Long Landlord / Mortgage Company Name Phone Employment Information Employer * Position * Address * How Long * City * State * select state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Co-Applicant Employer Position Address How Long City State select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Gross Income * Select One * Weekly Bi-Weekly Monthly Notice: Alimony, child support, or separate maintenance income need not be revealed if the applicant or co-applicant does not want to include it in the total household income Other Income Amount If employed in current position for less than two years, please complete the following Previous Employer Position Address How Long City State select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Credit Information Please list all debts separately. Indicate in the last block whether the debt belongs to the Applicant or Co-Applicant. Creditor Monthly Payment Select One Applicant Co-Applicant Child Support Payments Alimony Payments Authorization to release information I/We hereby authorize the release to Coldwell Banker Active Real Estate, or its assigns, of any and all informatin they may require at any time for any purpose related to our application. I/We authorize Coldwell Banker Active Real Estate, or its assigns, to release information to any entity further they deem necessary for any purpose to the transaction of this application. I/We further authorize Coldwell Banker Active Real Estate, or its assigns, to contact and make inquiries of my/our lenders, creditors, landlords, employers, and other persons deemed necessary and appropriate by Coldwell Banker Active Real Estate, or its assigns, to obtain or verifty information for the purpose related to my prequalification application. Hold Harmless Disclaimer I/We release Coldwell Banker Active Real Estate, and its trusees, officers, directors, employees, and agents (collectively, the "Indemnified Parties") from any liability of damages resulting from such contacts and inquiries. I/We agree to indemnify and hold harmless the Indemnified Parties from and against any liability, claims, damages, costs, and expenses (including attorney fees and costs) incurred by or asserted against any of them as a result of this application. Credit Report I/We herby authorize Coldwell Banker Active Real Estate to obtain my/our credit report for a fee of $25.00 per person. Applicant's Aggreement The undersigned understands that this applicatin has been prepared soley for determining mortgage eligibility. Any false statements or misrepresentation made of this application are cause for rejection. The applicant agrees that all information included in the application is valid, honest, and complete. Applicant Signature * Date * Co-Applicant Date Send