This form is only to be used to submit a formal application for credit! Please do not use this form for pre-qualifications, rate information, etc.

General Information

How did you hear about us? Select One Select One Previous Customer Microsurf Internet Services National Financial News Service My Local Newspaper National Paper Peeke Report The Mortgage Rate Directory www.NFNS.com www.MortgageQuotes.com www.loanfax.com www.interestratesonline.com www.virtualrelocation.com Mindspring Yellow Pages Directly From A Search Engine I Don't Remember Other

Which Search Engine, Newspaper, Other?

Have you been contacted by anyone from our_company? Yes  No  
If yes, who contacted you?

Loan Purpose

Purchase   Refinance   2nd Mortgage/Line of Credit
For Purchases only: Source of Down payment/Closing Costs coming from

Subject property is/will be: Primary Residence   Second Home  
                                         Investment (you will not live in property)

Address of Subject property:

City:    State:    ZIP Code:

Type of property: House 2-4 family Condo Townhome Other

Estimated Value of property:
Type of Loan requested: Fixed 1 year ARM 3/1 ARM 5/1 ARM 7/1 ARM 10/1 ARM Balloon Other        Loan Amount:

Interest Rate:         Term (Number of years 5-30):

Primary Borrower completeLeft side/ Co-Borrower complete Right side

Black areas to be completed by either borrowers

Contact/Borrower('s) Personal Information
Primary Borrower	Name (First, Middle, Last, Suffix)	Co-Borrower
	Complete E-mail Address
	Current Residence Address
	City, State, Zip Code
	Time at Current Residence
	Home Telephone Number
	Work Telephone Number
	Fax Number
	Social Security Number
	Age
	Years of Schooling
	Marital Status (Married / Unmarried / Separated)

Employment/Income Information
	Name of Present Employer
	Address of Present Employer
	City, State, Zip Code
	Time on this job (Years/Months)
	Current Position or Title
	Gross Monthly Base Income
	Monthly Overtime
	Monthly Bonus/Commissions
	Other Monthly Income #1

(Note: Other Income need not be revealed if you choose not to have it considered for repaying this loan)

	Source of Other Income #1
	Other Monthly Income #2
	Source of Other Income #2

Liability/Debt Information (List Joint Debts only once)
	Name of Creditor #1
	Monthly Payment
	Name of Creditor #2
	Monthly Payment
	Name of Creditor #3
	Monthly Payment
	Name of Creditor #4
	Monthly Payment
	Name of Creditor #5
	Monthly Payment

Alimony/Child Support
	Payable to
	Monthly Payment

Assets Bank/Stock Accounts
	Name of Institution
	Address
	City, State, Zip Code
	Account Number

   Checking   Savings       Account Type       Checking   Savings
Money Market     CD                            MoneyMarket   CD
Investment/Other   IRA                            Investment/Other   IRA

Other Assets
	Auto (Year/Model/Value)
	Auto (Year/Model/Value)
	Boat / other Vehicle
	Personal property (Value only)
	Other (Describe/Value)

Other property Currently Owned

Property Address:

City: State: ZIP Code:

Type of property: House 2-4 family Condo Townhome Other

Property Value:
Current Mortgage Company:
Current Monthly Payment:
Gross Monthly Rental Income:



Property Address:

City: State: ZIP Code:

Type of property: House 2-4 family Condo Townhome Other

Property Value:
Current Mortgage Company:
Current Monthly Payment:
Gross Monthly Rental Income:



Property Address:

City: State: ZIP Code:

Type of property: House 2-4 family Condo Townhome Other

Property Value:
Current Mortgage Company:
Current Monthly Payment:
Gross Monthly Rental Income:

Declarations

Yes No	Are there any outstanding judgements against you?	Yes No
Yes No	Have you filed bankruptcy in the past 7 years?	Yes No
Yes No	Have you had a Foreclosure or given deed or title of property in lieu of foreclosure in the past 7 years?	Yes No
Yes No	Are you obligated to pay Alimony, Child Support, or Separate Maintenance	Yes No
Yes No	Are you a co-signor or guarantor on a loan or other note?	Yes No
Yes No	Do you currently have, or intend to submit, an application for financing of this property to any other type of mortgage lender?	Yes No
	If yes, with whom?
U.S. Citizen Resident Alien Non-Resident Alien Other	Citizenship:	U.S. Citizen Resident Alien Non-Resident Alien Other

Information for Government Monitoring Purposes

The following information is requested by the Federal Government in order to monitor the Lender's compliance with equal credit, fair housing, and other mortgage disclosure laws. You are not required to furnish this information, but are encouraged to do so. The laws provide that a Lender may neither discriminate on the basis of this information, nor on whether you choose to furnish it. If you do not wish to furnish this information, please type/select "Do not want to disclose".

Do not want to disclose	Race/National Origin:	Do not want to disclose
Male Female	Sex:	Male Female

Certification

I/We certify that the information provided in this application is true and correct as of this date and acknowledge my/our understanding that any intentional or negligent misrepresentation(s) of the information contained in this application may result in civil liability and/or criminal penalties including, but not limited to, fine, or imprisonment or both under the provisions of Title 18, United States Code, Section 1001, et seq, and liability for monetary damages to the Lender, its agents, successors and assigns, insurers and any other person or entity who may suffer any loss due to reliance upon any misrepresentation which I/We have made on this application.

I/we further authorize Mandarin Mortgage and/or its assigns to pull my/our Credit Reports for the purpose of this application. I/We further authorize our employer(s), banking institutions, landlords, or any other third party, whether an individual or entity, to release all necessary information needed to process our application for financing.

By "Submitting" this application, I/We certify the above declarations even though my/our actual signatures may not be present on this application. We further authorize any third party to release any necessary information even though my/our actual signatures may not be present on this form.

How do you wish to be contacted?

Home Phone   Work Phone   E-mail   Regular Mail

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Mandarin Mortgage Corp.
Corporate Office: 3910 Northdale Blvd Ste 208 • Tampa, FL  33624
800-626-3746 • FAX: 813-264-6263 • E-Mail

©  Copyright Mandarin Mortgage Corp.