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Section A: Mortgage Lates

Within the last 24 months have you had any late payments on your mortgage?

If yes, continue, otherwise skip to section B.

Number of Mortgage Lates

Within the last 12 months

Between 13 and 24 months ago

30-59 days late

60-89 days late

90+ days late

Are you currently late on your mortgages?

Section B: Consumer Loan Lates

Have you had any late payments on your credit cards, auto loans, student loans or any other consumer debts?

If yes continue, otherwise skip to section C.

Number of Consumer Lates

Within the last 12 months

Between 13 and 24 months ago

30-59 days late

60-89 days late

90+ days late

Are you currently late on your consumer loan payments?

Section C: Collections, Charge offs, Judgements, Tax Lien

Do you have any collections, charge offs, judgements or tax liens?

Section D: Bankruptcies

Have you been bankrupt during the last 7 years?

Section E: Foreclosures

Have you had any foreclosures during the last 7 years?

Section F: Payment load

Do you have a lot of consumer debts, such as credit cards, auto loans, student loans, etc.?

Section G: Equity in your property

The value of my house is $
The total amount of loans on my house are $

First Southeast Mortgage - 2700 Highway 280 East - Birmingham, AL 35223
Office Phone: (205) 871-7300 Fax: (205) 871-7303

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NAMB - National Association of Mortgage Brokers