1395 Columbia Road South
Grand Forks, North Dakota 58201
Phone: (218) 779-3118
Fax: (203) 779-3115
e-mail ihetim@shopgf.biz
PREQUALIFICATION AUTHORIZATION FORM BORROWER CO-BORROWER
CO-BORROWER______________________________________________________________________________________
____________________________________________ Complete Legal Name Complete Legal Name
Complete Legal Name ______________________________________________________________________________________
____________________________________________ Social Security NumberAgeSocial Security NumberAge
AgeSocial Security NumberAge ______________________________________________________________________________________
____________________________________________ Address City/State ZipAddress City/State Zip
Address City/State Zip_____________________________________________________________________________________
____________________________________________ Home PhoneWork PhoneHome PhoneWork Phone
Work PhoneHome PhoneWork PhoneSelf Employed (Please Circle) Yes No Self Employed (Please Circle) Yes No
Self Employed (Please Circle) Yes No_________________________________________ ____________________________________________
____________________________________________ Employer Position / Title Employer Position / Title
Position / Title Employer Position / Title Years on Job ______Years in line of Work _____Years on Job _____ Years in line of Work _____
Years on Job _____ Years in line of Work _____Gross Monthly Income ____________________ Gross Monthly Income _______________________
Gross Monthly Income _______________________Other Income ____________________________ Other Income _______________________________
Other Income _______________________________Source of Income ________________________Source of Income ___________________________
Source of Income __________________________________________________________________________________________________
ASSETS
Funds on deposit (savings, checking,money market) $ ___________________________
Own Land ______ Yes ______ No Value $______________ Pay Off $____________
_______________________________________________________________________
LIABILITIES
Creditor Account Number Payment Balance Mortgages: ________________ ________________ ______ ______________
______ ______________ Auto: ________________ ________________ ______ ______________
________________ ________________ ______ ______________ St. Loan: ________________ ________________ ______ ______________
________________ ________________ ______ ______________ Installments: ________________ ________________ ______ ______________
______ ______________ ________________ ________________ ______ ______________ Revolving: ________________ ________________ ______ ______________
______ ______________ Other: ________________ ________________ ______ ______________
________________ ________________ ______ ______________ **Additional assets and liabilities (including alimony or child support) should be listed on a seperate sheet of paper and included with this sheet.
AUTHORIZATION TO RELEASE INFORMATION SHEET
I/We are requesting that Landmark Home & Land Company and any of it's lenders completes a pre-qualification to determine if I/we qualify for a loan. I/we authorize the recipient of this authorization to release any and all information pertaining to my credit history, income, bank, money market and similar account balances to Landmark Home & Land Company and any of it's lenders for the above stated purpose. A copy of this authorization may be as an orginal.
__________________________________________ ________________________________________________
________________________________________________ Borrower's Signature Date Co-Borrower's Signature Date
Date Co-Borrower's Signature Date You may print this form and Fax it to (203) 779-3115
