Reverse Mortgage OnLine Application

Preeliminary

Reverse Equity Mortgage Application

In order to be able to prepare the full Application, please fill the following information. Please be as complete as possible. There is some information on your property and other personal information which we will obtain from the county or from you either personally or by Telephone.

Should you have any questions or doubts please contact me at

786-262-6486

Note: Information kept confidential. It is not shared with any third party except to process, obtain approval and close this loan.

Preeliminary Application Form - Reverse Mortgage

Please fill out all the required fields in order that we may prepare the
full application documents. Names should be as they appear on Florida
Drivers Licence or Florida ID.

If you prefer you can print the form and fax it to 786-345-0783

If you are submitting this preeliminary application request form for
the Applicants, please include your Name Telephone, email and
Relationship to them.

Application Form Fields REM

*Name:
*Applicant 1 Date of Birth (mm/dd/year):
*Applicant 1 (Married - Unmarried):
*Phone:
Is This the Applicants' Phone?:
Alternate Phone or Cell (incl. area code) :
Best Time To Contact you? (am/pm):
*Email:
Applicants' Fax (if any):
Applicant 2 Full Name (if any):
Applicant 2 Date of Birth (mm/dd/year):
*Home Address (full) include unit #:
*City:
*Zip Code:
*Florida County:
*Your Estimate of Home Value $:
*Outstanding Balance 1st Mortgage $:
Outstanding Balance 2nd Mortgage $:
Other Liens? (taxes,IRS,judgements) $:
*Type of Home (Single,Condo, Duplex, Coop, Townhse):
*Have you been Counseled by HUD?:
Bankruptcy? (if yes, Chpt. & Date Discharged):
Are you in Foreclosure? Since When?:
Name, Address, Tel # of Alternate Contact 1:
Name, Address, Tel # of Alternate Contact 2:
Name, Phone and Relationship of Person submitting?:
If not Borrower, Do U have a Power of Attorney?:
Are You Primary Contact?:

Note: Fields with an * are required

A Senior Helping Seniors With Ethics And Consideration! Juan Luis Rodriguez-Kohly Your Trusted Reverse Mortgage Specialist Banking Mortgage Services Corp 5820 SW 40th St (Bird Road) Miami FL 33155 Tel: 786-262-6486 305-445-9003 ext 114 Toll Free (USA): 1-866-215-2143 ext 114 RodKohly@HappySeniorHomeOwners.com