Rent Own Other

Hour Week Two weeks Month Year

Hour Week Two weeks Month Year

Poor Good Fair Excellent

car loan

credit card

student loan

personal loan

child support

other

First Name

E-mail address

Comments, questions, concerns etc

Home address line 1

Home address line 2

Home address city state zip

How long at current address

years and

months

Do you own or rent?

Last Name

Current monthly housing cost

Primary employer / income source

How long with this employer

years and

months

Gross income (before any withholdings) Dollars

per

Secondary employer / income source

How long with this employer

years and

Gross income (before any withholdings) Dollars

per

months

I think my credit report is

I have this amount in the bank today to use toward down payment and closing costs

I would like my new housing cost to be this much per month including the home loan and all property taxes and insurance

I have these monthly payments

Phone numbers Numbersdress