Quick Lead
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Brokaw Capital Mortgage Quick Lead
97 East Brokaw Rd. #200 San Jose, CA 95112
Applicant Full Name
Co-Applicant Full Name
Date of Birth
Date of Birth
Social Security Number -
Social Security Number -
-
Job Title
Monthly Income $ Yrs
Current Address
Job Title Monthly Income Yrs $
How long have you lived at this address? yrs Phone Numbers Home ( )
Phone Numbers Home ( ) Cell
(
-
)
Cell
(
)
What is your current monthly house payment? $ Does that payment include taxes and insurance? Yes or No Is there a pre-payment penalty? Yes or No Is this a refinance or a purchase? Circle one: R or P If a purchase, what is the address of the new home?
How much do you owe on the house currently $
What is the purchase price? $ How is the property zoned?
Residential
Commercial
Agricultural
(Circle one)
If a refinance, what is the main purpose for this loan? What is the requested loan amount? $
Lower Payment Consolidate Debt
Change Program Combine Loans Cash Out
Is this a Single Family Residence? Or a Multi Family Residence?
Mobile home? Condo? Townhouse?
(Check one)
What are your liquid assets? $
Retirement fund $
Do you intend to occupy the home? Yes No
Is this a second (vacation) home? Yes No
What kind of loan do you want?
30-yr Fixed
15-yr fixed
Adjus. Rate Mort
(Please Circle)
Option Arm
Hybrid
Other
Int. Only
(Circle one)
Stated or Full Doc? (Circle)
If stated, you will be required to sign a stated
W2 or Self Employed (Circle)
income declaration form
I have been granted verbal authorization from the above name applicants to obtain the information itemized immediately above. Dated Please Print Name: SLO LO QMD Contact Email
Phone Number ( ) ( ) ( )
Other Notes:
(Circle)
Signature of L.O. X
Estimated Property Value (E.P.V.) $ Requested Bank:
OK
WFG Code # WFG Code # WFG Code # Loan to Value (L.T.V)
%
97 East Brokaw Rd. #200 San Jose, CA 95112
Applicant Full Name
Co-Applicant Full Name
Date of Birth
Date of Birth
Social Security Number -
Social Security Number -
-
Job Title
Monthly Income $ Yrs
Current Address
Job Title Monthly Income Yrs $
How long have you lived at this address? yrs Phone Numbers Home ( )
Phone Numbers Home ( ) Cell
(
-
)
Cell
(
)
What is your current monthly house payment? $ Does that payment include taxes and insurance? Yes or No Is there a pre-payment penalty? Yes or No Is this a refinance or a purchase? Circle one: R or P If a purchase, what is the address of the new home?
How much do you owe on the house currently $
What is the purchase price? $ How is the property zoned?
Residential
Commercial
Agricultural
(Circle one)
If a refinance, what is the main purpose for this loan? What is the requested loan amount? $
Lower Payment Consolidate Debt
Change Program Combine Loans Cash Out
Is this a Single Family Residence? Or a Multi Family Residence?
Mobile home? Condo? Townhouse?
(Check one)
What are your liquid assets? $
Retirement fund $
Do you intend to occupy the home? Yes No
Is this a second (vacation) home? Yes No
What kind of loan do you want?
30-yr Fixed
15-yr fixed
Adjus. Rate Mort
(Please Circle)
Option Arm
Hybrid
Other
Int. Only
(Circle one)
Stated or Full Doc? (Circle)
If stated, you will be required to sign a stated
W2 or Self Employed (Circle)
income declaration form
I have been granted verbal authorization from the above name applicants to obtain the information itemized immediately above. Dated Please Print Name: SLO LO QMD Contact Email
Phone Number ( ) ( ) ( )
Other Notes:
(Circle)
Signature of L.O. X
Estimated Property Value (E.P.V.) $ Requested Bank:
OK
WFG Code # WFG Code # WFG Code # Loan to Value (L.T.V)
%
