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Brokaw Capital Mortgage 97 East Brokaw Rd.

Quick Lead 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 Job Title Monthly Income

Yrs Yrs $

Current Address
How long have you lived at this address? yrs

Phone Numbers Phone Numbers
Home ( ) Home ( )
Cell ( ) Cell ( )
What is your current monthly house payment? $
Does that payment include taxes and insurance? Yes or No How much do you owe on
Is there a pre-payment penalty? Yes or No the house currently $
Is this a refinance or a purchase? Circle one: R or P
If a purchase, what is the address of the new home?
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? Lower Payment Change Program
Consolidate Debt Combine Loans
What is the requested loan amount? $ Cash Out
Is this a Single Family Residence? Mobile home?
Or a Multi Family Residence? 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 (Circle one)
(Please Circle) Int. Only Option Arm Hybrid Other
Stated or Full Doc? (Circle) If stated, you will be required to sign a stated
W2 or Self Employed (Circle) income declaration form OK (Circle)
I have been granted verbal authorization from the above
name applicants to obtain the information itemized
immediately above. Dated Signature of L.O. X
Please Print Name: Phone Number
SLO ( ) WFG Code #
LO ( ) WFG Code #
QMD ( ) WFG Code #
Contact Email
Estimated Property Value (E.P.V.) $ Loan to Value (L.T.V) %

Requested Bank:
Other Notes: