Customer name:
Address:
City:
State:
Zip:
Telephone:
E-mail:
Social Security Number:
Current value of house:
Date of purchase?
How much do you currently owe in your mortgage(s)?
Property location:
How do you think your credit is?
Are you employed?  yesno
Length of employment
Amount made in the last 2 years?
Are you self employed? yesno
What is your adjusted gross income?
How long do you own?
Do you need cash from this transaction? yesno
Do you want to consolidate any payment? yesno
Any additional comments?

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