Liberty Mortgage, Inc.

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By submitting this form, you authorize Liberty Mortgage, Inc. to request and receive information regarding your credit in the form of a credit report.

Name:
Address:
Apt#:
City:
State:
Zip:
Home phone:
Work phone:
E-mail Address:
Social Security #:

Spouse/Co-borrower's name:
Social Security #:
Number Dependents:

Name of Employer:
Title:

Length of employment in this position:
Length of time in this profession:
Present salary per month-(before taxes):

Marital Status

Single

Married

Other

Spouse/Co-borrower's employer:
Phone:
Title:

Length of employment in this position:
Length of time in this profession:
Present salary per month-(before taxes):

What is the best place for a Loan Officer to contact you?:

Home
Work

What is the best time for a Loan Officer to contact you?:

a.m.
p.m.

Cash for down payment:
Will this be a purchase or refinance?: Purchase Refinance
If purchasing, what is the purchase amount:
If refinancing, what is the approximate value of your home:

Anticipate amount needed to borrow:
Number of Mortgages Owned:

Other Assets (specify)
Mortgages		Lender..................................Balance..........Monthly Payment
Auto Loans		Lender..................................Balance..........Monthly Payment
Credit Cards		Lender..................................Balance..........Monthly Payment
Student Loans		Lender..................................Balance..........Monthly Payment
Other Loans		Lender..................................Balance..........Monthly Payment
Child Support And other obligations
Additional information that may assist us in determining your particular loan needs.

Contact Information

	Address:	1363 Commercial ST SE Salem OR 97302
	Phone Number:	(503) 363-9896
	Email:	Mark Oehler David Halter