Borrower
	first name	(mi)	last name
	Social Security Number	Marital Status	Home Phone Number
		Single Married Divorced
	Email Address	Age
Present Address		City	State	Zip
Co-Borrower
	first name	(mi)	last name
	Social Security Number	Marital Status	Home Phone Number
		Single Married Divorced
	Email Address	Age
Present Address		City	State	Zip
I would like to be contacted by			E-mail Phone Mail
Gross Monthly Income of Borrower
Gross Monthly Income of Co-Borrower
Total Assets
Toal Minimum Monthly Debts of Borrower Toal Minimum Monthly Debts of Co-Borrower Loan Type Purchase Refinance Equity Line Not Sure   Loan Amount   Property Value/Purchas Price How would you rate your credit? Excellent Good Average Some Problems Poor Are you aware of any derogatory information on your credit? Yes No Will any portion of your down payment be borrowed? Yes No Are you intending this property be non-owner occupied? Yes No

By Submitting, I/We authorize United Pacific Mortgage to obtain a consumer credit report containing my/our credit history for the purpose of pre-qualifying for a mortgage.