Name *

First Name

Last Name

When would you plan on purchasing a home? *

0-3 Months

3-6 Months

6-12 Months

Will any of your down payment be in the form of a gift? *

Yes

No

How would you best describe your financial philosophy? *

Conservative

Moderate Risk Taker

Risk Taker

Do you foresee incurring other financial obligations within the next 5 years? *

Check any or all that apply

A New Car

College Expense

Planning to Have a Baby

New Job/Career Change

Which of the following personal goals are most important to you? *

Check any that apply

Building your net worth

Moving to a larger home

Having your mortgage paid off when you retire

Achieving financial freedom

Saving money to send kids to college

Investing in the stock market

What is most important about this mortgage to you? *

Check any that apply

Lowest payment

Lowest closing costs

Improve credit history

Eliminating other debt

Maximize tax benefits

Paying loan off ASAP

Lowest down payment

Do you work with a financial planner? *

Yes

No

If yes, how happy are you with their services?

★

★★

★★★

★★★★

★★★★★

Do you work with a life insurance agent? *

Yes

No

If yes, how happy are you with their services?

★

★★

★★★

★★★★

★★★★★

What is the best way to contact you? *

Phone

Email

Text

Phone Number *

(###)

###

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