St. Address:

City:

State:

Home Phone:

My Code of Ethics Requires that I make sure about this:

** If both names are on accounts for debts below, enter debts once and don't duplicate.

YOU (BORROWER #1)

(Other) BORROWER #2

Name1:

Name2:

SS#:

SS#:

Birth Date:

Birth Date:

Employer:

Employer:

List all employers (include dates) for past 2 years:

List all employers (include dates) for past 2 years:

$Income:

$Income:

  (Gross, before deducting taxes, etc.)

  (Gross, before deducting taxes, etc.)

$Debts/Mo.:

$Debts/Mo.:

  (Pymts for loans, credit card minimums)

  (Pymts for loans, credit card minimums)

$Down Pymt:

$Down Pymt:

  (Amount most PROBABLE for you)

  (Amount most PROBABLE for you)

Source:

Source:

of Down Payment

  (such as savings, gift, 401-k, CASH, etc.)

of Down Payment

 (such as savings, gift, 401-k, CASH, etc.)

*** PLEASE CHECK ONE OPTION BELOW

IF YOU SELECT "NO", THE APPROVAL WE SUBMIT WILL BE SUBJECT TO CREDIT APPROVAL.

NONE OF THIS INFORMATION WILL BE SHARED WITH ANY OTHER PARTY.

Larry Hathcock, Broker

Licensed in Georgia

101 N. Thornton Ave. Suite 211 Dalton, GA 30720-4282

Phone: 706.275.9755 Fax: 706.275.9742