Loan Officer (if assigned):

Home Owner's Information:

Spouse's Information:

Name:

Name:

Date of birth:

Date of birth:

Phone number:

Address:

Qualifying Questions:

1. Are both spouses at least 62 years of age?

2. What, if any, is the balance of the existing mortgage?

3. What is the approximate market value of the home?

Is there anyone else on the deed other than the homeowner and/or spouse:

If yes, indicate name and relationship to homeowner and/or spouse:

Type of Dwelling:

Point of contact for information (if different than homeowner):

Name:

Phone number:

Address: