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Co-Borrower

First Name
Last Name
Street Address
Apt #
City
State
Zip Code
E-mail Address
Home Phone
Work Phone
Social Security #
Employer
Self-Employed?	yes   no
Length of Employment
Gross Monthly Income	$
Other Income (please describe)

Current Monthly Debts

Mortgage / Rent	$
2nd Mortgage / Equity Loans	$

Loan Request

Amount Requested $
Reason for Loan: (please choose one of the following)
	New Home Purchase (owner occupied)
	Real Estate Investment
	Debt Consolidation
	Lower Interest Refinance
	Repair Damaged Credit
	Home Improvements
	College Tuition Expenses
	Other

Property & Loan Information

( For New Home Purchases )
Purchase Price	$
Available Funds	$
( For Refinances )
Estimated Value of Current Home	$
Mortgage Balance (sum of 1st + 2nd mortgages)	$
Do you own additional properties?	yes no

Referral Source

How did you hear about Flaherty Funding?

Additional Information

Please type in the box below, any information that you feel would be helpful to the mortgage experts at Flaherty Funding, in determining the best loan for you ...

Authorization: In submitting this form, I (we) authorize Flaherty Funding Corp. to obtain a credit report and verify my (our) business and employment history for the purpose of securing a mortgage loan. Submission of this form in no way constitutes an obligation on the part of either party.

(Please be patient. It may take up to 2 minutes to complete the submission.)