State you are Refinancing in: Select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *

Approximate CURRENT value of home to be refinanced: Select... Please Select... under $50,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 $110,000 $120,000 $130,000 $140,000 $150,000 $160,000 $170,000 $180,000 $190,000 $200,000 $210,000 $220,000 $230,000 $240,000 $250,000 $260,000 $270,000 $280,000 $290,000 $300,000 $310,000 $320,000 $330,000 $340,000 $350,000 $360,000 $370,000 $380,000 $390,000 $400,000 over $400,000 *

How much do you currently owe on your home? Select... Please Select... under $50,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 $110,000 $120,000 $130,000 $140,000 $150,000 $160,000 $170,000 $180,000 $190,000 $200,000 $210,000 $220,000 $230,000 $240,000 $250,000 $260,000 $270,000 $280,000 $290,000 $300,000 $310,000 $320,000 $330,000 $340,000 $350,000 $360,000 $370,000 $380,000 $390,000 $400,000 over $400,000 *

What is your current Interest Rate? *

Is your rate fixed or adjustable? Fixed Adjustable

Is your current home loan a VA Home Loan? Yes No

Are you currently late in making your payments? Yes No

If late, how late are you in making your payments? Select.. 1 Month 2 Months 3 Months 4 Months 5 Months 6 Months 6 Months Or More

Do you want to stay in your current home? Yes No

Could you make a reduced monthly payment on your mortgage? Yes No

Have you experienced any financial hardships in the last year? Yes No

If so, please check the box or boxes that apply to your specific situation:
Loss of employment
Loss of or reduced income
A recent divorce or separation
A recent medical condition and/or overwhelming medical bills
Excessive debt
Death of a spouse, family member, or co-income generator
Increase of monthly payment obligations
Loss or failure of Business
Illness and/or medical condition that interferes with income generating abilities
Property damage or destruction
Call to Military service
Incarceration
Inability to refinance due de-valuation of property, recent credit derogatories, etc.
Other (please specify)

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