CRAIG  CHIELLO  -  V.P.      (PLEASE PRINT THIS FORM, FILL IT OUT, AND FAX IT TO ME)

Stamford Mortgage Co.

Tel. (203)461-9330

Fax (203)329-8463           

      Referred By: ________________________/ Title: Realtor__  Attorney__  Internet__

Borrower Name: ____________________________                  

__ Married __Unmarried __Separated

Home Phone Number: _____________Work Phone Number: _____________

Cell Phone Number:  ______________   Email Addr:___________________  

Date of Birth: ___________Social Security Number: ______________

Present Home:     ____ Number of Years                       How do you rate your credit history?:

__Rent  __Own                                                                     ___ Good   ___Avg.   ___Poor

Street Addr._________________________________                                                                   

City: ___________________________ State: __________________Zip: _______

   
Co-Borrower Name: _________________________       __ Married __Unmarried __Separated

Home Phone Number: _____________Work Phone Number: _____________

Cell Phone Number:  ______________   Email Addr:___________________  

Date of Birth: ___________Social Security Number: _______________

Present Home:      ____ Number of Years                      How do you rate your credit history?:

__Rent           __Own                                                             ___Good    ___Avg. ___Poor

Street Address:______________________________                                                       

City: ___________________________ State: __________________Zip:_______

Purpose of the loan:   __Purchase  __Refinance  __Construction

Property will be:         __Primary Residence  __Secondary Home  __Investment Property

LoanAmountRequested:   $___________

Type of loan requested:                                 

__Conventional      __Jumbo     __Non-Income Verification

Monthly Income:                 Borrower:             Co-Borrower:        Total:

Base Employment Income:    $_________               $__________            $ __________         

Borrower: Self-employed? ___ Yes ___No    Co-Borr.: Self-Employed? __ Y ___ N  

                         Overtime:     _________                 __________               __________

                           Bonuses:    _________                 __________               __________      

                    Commissions:    _________                 __________               __________      

                             Other:      _________                 __________               __________      

                             Total:     $_________               $__________             $__________

Combined Monthly Obligations -             (Borrower and Co-Borrower):

                                                         Rent Payment:              _________

                                                         Mortgage Payment:       _________

                                                             Other Payments:       _________

                                                                            Total:     $_________

If checked below, Borrower and Co-Borrower authorize lender to use this information

to pre-qualify them for the type of loan stated above and to secure their credit report(s).

___Yes  ___No -   Run my(our)creditreport(s)

Signature(s) -(Optional)/___________________  Date________

                                    ___________________  Date________

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