Residential Mortgage Application Form

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This application is designed to be completed by the applicant(s) with the lender's assistance. Applicants should complete this form as "Borrower" or "Co-Borrower", as applicable. Co-Borrower information must also be provided (and the appropriate box checked) when the income or assets of a person other than the "Borrower" (including the Borrrower's spouse) will be used as a basis for loan qualification or the income or assets of the Borrower's spouse will not be used as a basis for loan qualification, but his or her liabilities must be considered because the Borrower resides in a community property state, the security property is located in a community property state, or the Borrower is relying on other property located in a community property state as a basis for repayment of the loan.

I. Type of Mortgage and Terms of Loan

Mortgage Applied for: VA
Conventional
FHA
USDA/Rural Housing Service
Other:
Agency Case Number:
Lender Case Number:
Amount:
Interest Rate: %
No. of Months:
Amortization Type: Fixed Rate
GPM
Other (explain):
ARM (type):

II. Property Information and Purpose of Loan

Subject Property Address:
(street, city, state, ZIP)
No. of Units:
Legal Description of Subject Property:
(attach description if necessary)
Year Built:
Purpose of Loan: Purchase
Construction
Refinance
Construction-Permanent
Other (explain):
Property will be: Primary Residence
Secondary Residence
Investment
Complete this section if construction or construction-permanent loan. Complete this section if this is a refinance loan.
Year Lot Accquired:
Original Cost:
Amount Existing Liens:
(a) Present Value of Lot:
(b) Cost of Improvements:
Total (a + b)
Year Accquired:
Original Cost:
Amount Existing Liens:
Purpose of Refinance:
Describe Improvements: made to be made
Cost
Title will be held in what Name(s)
Manner in which Title will be held
Estate will be held in: Fee Simple
Leasehold (show expiration date)
Source of Down Payment, Settlement Charges and/or Subordinate Financing (explain)

III. Borrower Information

Borrower's Name
(include Jr. or Sr. if applicable)
   Co-Borrower's Name
(include Jr. or Sr. if applicable)
Social Security Number Social Security Number
Home Phone
(incl. area code)
Home Phone
(incl. area code)
DOB
(MM/DD/YYYY)
DOB
(MM/DD/YYYY)
Yrs. School Yrs. School
  Married
Separated
Unmarried (include single,
      divorced,widowed)
  Married
Separated
Unmarried (include single,
      divorced,widowed)
Dependents No.
(not listed by Co-Borrower)
Ages

Dependents No.
(not listed by Borrower)
Ages

Present Address
(street, city, state, ZIP)
Present Address
(street, city, state, ZIP)
  Own Rent
No. Yrs.
  Own Rent
No. Yrs.
Mailing Address,
if different from Present Address
Mailing Address,
if different from Present Address
 
If residing at present address for less than two years, complete the following
Former Address
(street, city, state, ZIP)
Former Address
(street, city, state, ZIP)
  Own Rent
No. Yrs.
  Own Rent
No. Yrs.

IV. Employment Information

Borrower Co-Borrrower
Name & Address
of Employer

Self Employed
Name & Address
of Employer

Self Employed
Yrs. on this job Yrs. on this job
Yrs. employed in this line of work/profession Yrs. employed in this line of work/profession
Position/Title/Type of Business Position/Title/Type of Business
Business Phone
(incl. area code)
Business Phone
(incl. area code)

If employed in current position for less than two years or if currently employed in more than one position, complete the following:
Name & Address
of Employer

Self Employed
Name & Address
of Employer

Self Employed
Dates (from - to) Dates (from - to)
Monthly Income Monthly Income
Position/Title/Type of Business Position/Title/Type of Business
Business Phone
(incl. area code)
Business Phone
(incl. area code)
  
Name & Address
of Employer

Self Employed
Name & Address
of Employer

Self Employed
Dates (from - to) Dates (from - to)
Monthly Income Monthly Income
Position/Title/Type of Business Position/Title/Type of Business
Business Phone
(incl. area code)
Business Phone
(incl. area code)

V. Monthly Income and Combined Housing Expense Information

Gross Monthly Income Borrower Co-Borrower Total
Base Empl. Income*
Overtime
Bonuses
Commissions
Dividends/Interest
Net Rental Income
Other
(before completing, see the notice in "describe other income", below)



Total
 
Combined Monthly Housing Expense Present Proposed  
Rent    
First Mortgage (P&I)  
Other Financing (P&I)  
Hazard Insurance  
Real Estate Taxes  
Mortgage Insurance  
Homeowner Assn. Dues  
Other  
Total  
* Self Employed Borrower(s) may be required to provide additional documentation as tax returns and financial statements.

Describe Other Income
Notice: Alimony, child support, or separate maintenance income need not be revealed if the Borrower (B) or Co-Borrower (C) does not choose to have it considered for repaying this loan.
B/C   Monthly Amount

VI. Assets and Liabilities

This Statement and any applicable supporting schedules may be completed jointly by both married and unmarried Co-Borrowers if their assets and liabilities are sufficiently joined so that the Statement can be meaningfully and fairly presented on a combined basis; otherwise separate Statements and Schedules are required. If the Co-Borrower section was completed about a non-applicant spouse, or other person, this Statement and supporting schedules must be completed about that spouse or other person also.
Completed Jointly Not Jointly

Assets   Cash or Market Value
Cash deposit toward purchase held by:

List checking and savings accounts below
Name and address of Bank, S&L,
or Credit Union:
Acct. no.  
Stocks & Bonds: (Company name/number & description)

Life insurance net cash value
Face amount

Subtotal Liquid Assets
Real estate owned (enter market value from schedule of real estate owned)
Vested interest in retirement fund
Net worth of business(es) owned (attach financial statement)
Automobile owned (make and year)
Other Assets (itemize)
Total Assets a.

Liabilities and Pledged Assets. List the creditor's name, address and account number for all outstanding debts, including automobile loans, revolving charge accounts, real estate loans, alimony, child support, stock pledges, etc. Use continuation sheet, if necessary. Indicate by (*) those liabilities which will be satisfied upon sale of real estate owned or upon refinancing of the subject property.
Liabilities Monthly Payment & Months Left to Pay Unpaid Balance
Name and address of Company
Acct. no.
Payment/Months

Alimony/Child Support/Separate mantenance Payments Owed to:  
Job Related Expense (child care, union dues, etc.):  
Total Monthly Payments:  
Total Liabilities b.:
Net Worth (a minus b):

Schedule of Real Estate Owned (If additional properties are owned, use continuation sheet.)
Property Address (enter S if sold, PS if pending sale or R if rental being held for income) Type of Property Present Market Value Amount of Mortgages & Liens Gross Rental Income Mortgage Payments Insurance, Maintenance, Taxes & Misc. Net Rental Income
  Totals

List any additional names under which credit has previously been received indicate appropriate creditor name(s) and account number(s)
Alternate Name Creditor Name Account Number

VII. Details of Transaction

a. Purchase price
b. Alterations, improvements, repairs
c. Land (if acquired separately)
d. Refinance (incl. debts to be paid off)
e. Estimated prepaid items
f. Estimated closing costs
g. PMI, MIP, Funding Fee
h. Discount (if Borrower will pay)
i. Total costs (add items a through h)
j. Subordinate financing
k. Borrower's closing costs paid by Seller
i. Other Credits (explain)
m. Loan amount (exclude PMI, MIP, Funding Fee financed)
n. PMI, MIP, Funding Fee financed
o. Loan amount (add m & n)
p. Cash from/to Borrower (subtract j, k, l & o from i)

VIII. Declarations

If you answer "yes" to any questions a through i, please use continuation sheet for explanation. Borrower    Co-Borrower
a. Are there any outstanding judgments against you? Yes No Yes No
b. Have you been declared bankrupt within the past 7 years? Yes No Yes No
c. Have you had property foreclosed upon or given title or deed in lieu thereof in the last 7 years? Yes No Yes No
d. Are you a party to a law suit? Yes No Yes No
e. Have you directly or indirectly been obligated on any loan which resulted in foreclosure, transfer of title in lieu of foreclosure, or judgment? (This would include such loans as home mortgage loans, SBA loans, home improvement loans, educational loans, manufactured (mobile) home loans, any mortgage, financial obligation, bond, or loan guarantee. If "Yes," provide details, including date, name and address of Lender, FHA or VA case number, if any, and reasons for the action.) Yes No Yes No
f. Are you presently delinquent or in default on any Federal debt or any other loan, mortgage, financial obligation, bond, or loan guarantee? If "Yes," give details as described in the preceding question. Yes No Yes No
g. Are you obligated to pay alimony, child support, or separate maintenance? Yes No Yes No
h. Is any part of the down payment borrowed? Yes No Yes No
i. Are you a co-maker or endorser on a note? Yes No Yes No
j. Are you a U.S. citizen? Yes No Yes No
k. Are you a permanent resident alien? Yes No Yes No
l. Do you intend to occupy the property as your primary residence? If "Yes," complete question m below. Yes No Yes No
m. Have you had an ownership interest in a property in the last three years? Yes No Yes No
(1) What type of property did you own — principal residence (PR), second home (SH), or investment property (IP)?
(2) How did you hold title to the home — solely by yourself (S), jointly with your spouse (SP), or jointly with another person (O)?

IX. Acknowledgment and Agreement

Each of the undersigned specifically represents to Lender and to Lender's actual or potential agents, brokers, processors, attorneys, insurers, servicers, successors and assigns and agrees and acknowledges that: (1) the information provided in this application is true and correct as of the date set forth opposite my signature and that any intentional or negligent misrepresentation of this information contained in this application may result in civil liability, including monetary damages, to any person who may suffer any loss due to reliance upon any misrepresentation that I have made on this application, and/or in criminal penalties including, but not limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Sec. 1001, et seq.; (2) the loan requested pursuant to this application (the "Loan") will be secured by a mortgage or deed of trust on the property described herein; (3) the property will not be used for any illegal or prohibited purpose or use; (4) all statements made in this application are made for the purpose of obtaining a residential mortgage loan; (5) the property will not be occupied as indicated herein; (6) any owner or servicer of the Loan may verify or reverify any information contained in the application from any source named in this application, and Lender, its successors or assigns may retain the original and/or an electronic record of this application, even if the Loan is not approved; (7) the Lender and its agents, brokers, insurers, servicers, successors and assigns may continuously rely on the information contained in the application, and I am obligated to amend and/or supplement the information provided in this application if any of the material facts that I have represented herein should change prior to closing of the Loan; (8) in the event that my payments on the Loan become delinquent, the owner or servicer of the Loan may, in addition to any other rights and remedies that it may have relating to such delinquency, report my name and account information to one or more consumer credit reporting agencies; (9) ownership of the Loan and/or administration of the Loan account may be transferred with such notice as may be required by law; (10) neither Lender nor its agents, brokers, insurers, servicers, successors or assigns has made any representation or warranty, express or implied, to me regarding the property or the condition or value of the property; and (11) my transmission of this application as an "electronic record" containing my "electronic signature," as those terms are defined in applicable federal and/or state laws (excluding audio and video recordings), or my facsimile transmission of this application containing a facsimile of my signature, shall be as effective, enforceable and valid as if a paper version of this application were delivered containing my original written signature.

Electronic Communications

Certain laws require us to provide specific information to you in writing, which means you have a right to receive that information on paper.   We may provide such information to you electronically if we first present this disclosure and obtain your consent to receive it electronically.  Your consent will also apply to any other person named on your account, product or service, subject to applicable law.  At times, we may still present you with paper disclosures, but as a basic proposition we need to know that you are willing to receive disclosures and other information electronically that otherwise must be provided on paper and that you have the hardware and software needed for access to this information.

After you consent to this disclosure, you will:

  • Have the right or option to have the information provided or made available on paper
  • Have the right to withdraw consent to receive the information electronically
  • After your consent, you may request, in writing, a paper copy of your disclosure at no charge to you   


The procedure used to withdraw consent applies to all of your transactions or services during your relationship with the bank:

  • Subject to applicable law, you may withdraw your consent to the electronic communications in writing to:
    Flushing Bank
          • 144-51 Northern Blvd.
          • Flushing, NY 11354
          • Second Floor
          • ATTN: Residential Loan Originations Dept.
  • Your withdrawal of consent is effective only after you have communicated your withdrawal to us in writing and we have had a reasonable period of time to act upon your withdrawal.
  • You will not be charged a fee for withdrawal of your consent including withdrawal of your consent should the bank change its hardware or software requirements


Hardware and Software Requirements

While you may be able to access and retain the electronic disclosures using other hardware and software, your personal computer needs to support the following requirements:

  • Access to the internet and an Internet browser which supports HTML 4.0 and 128bit encryption and JavaScript
  • You will need the latest version of Netscape Navigator or Microsoft Internet Explorer, along with an additional security download from Microsoft (Service Pack 2) to ensure a maximum (128-Bit) encryption.
  • For communications provided in PDF format, Adobe Acrobat Reader 6.0 or later versions is required

X. Information for Government Monitoring Purpose

The following information is requested by the Federal Government for certain types of loans related to a dwelling in order to monitor the lender's compliance with equal credit opportunity, fair housing and home mortgage disclosure laws. You are not required to furnish this information, but are encouraged to do so. The law provides that a lender may discriminate neither on the basis of this information, nor on whether you choose to furnish it. If you furnish the information, please provide both ethnicity and race. For race, you may check more than one designation. If you do not furnish ethnicity, race, or sex, under Federal regulations, this lender is required to note the information on the basis of visual observation or surname. If you do not wish to furnish the information, please check the box below. (Lender must review the above material to assure that disclosures satisfy all requirements to which the lender is subject under applicable state law for the particular type of loan applied for.)
 
Borrower: Co-Borrower:
I do not wish to furnish this information. I do not wish to furnish this information.
Ethnicity: Hispanic or Latino
Not Hispanic or Latino
Ethnicity: Hispanic or Latino
Not Hispanic or Latino
Race: American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Race: American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Sex: Female
Male
Sex: Female
Male

To be Completed by Interviewer
This application was taken by: Face-to-face interview
Mail
Telephone
Internet
Interviewer's Name
(print and type)
Interviewer's Signature Date
Interviewer's Phone Number
(incl. area code)
Name and Address of
Interviewer's Employer

Continuation Sheet/Residential Loan Application

Using this continuation sheet if you need more space to complete the Residential Loan Application. Mark B for Borrower or C for Co-Borrower.
Borrower:
Co-Borrower:
Agency Case Number:
Lender Case Number:
 
I/We fully understand that it is a Federal crime punishable by fine or imprisonment, or both, to knowingly make any false statements concerning any of the above facts as applicable under the provisions of Title 18, United States Code, Section 1001, et seq.


If Applicable:   Officer Name:   Dept/Branch: