Reverse Mortgage OnLine Application

Preeliminary

Reverse Equity Mortgage Application

Please fill the following information. Please be as thorough 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.

By completing this form, it does not obligate you in any form or manner nor do you incurr any cost. By Federal Law, you have until 3 days AFTER closing to cancel the Loan.

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 Request 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. View Privacy Policy:
http://HappySeniorHomeOwners.com/PrivacyPolicy

If you prefer you can print the form and fax it to 786-345-0783 or
emil it to RodKohly@gmail.com

If you are submitting this preeliminary 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

Helping Florida's HomeOwners
and HomeBuyers
With Ethics And Consideration!
I Understand You!

Juan Luis Rodriguez-Kohly
Your Trusted Mortgage Professional
Reverse Mortgage Specialist
NMLS: 257898

Direct Tel: 786-262-6486
305-445-9003 ext 118
RodKohly@GMail.com

Banking Mortgage Services Corp.
5820 SW 40th St (Bird Road), Miami FL 33155
NMLS: 257880

305-445-9003
License Information

Reverse Mortgage Specilist Diploma

Juan Luis Rodriguez-Kohly Loan Originator, Banking Mortgage Services Corp. 5820 SW 40th Street (Bird Road) Miami, FL 33155

Phone: Cell: Fax:

Copyright © 2012 Juan Luis Rodriguez-Kohly Loan Originator, Banking Mortgage Services Corp.
Portions Copyright © 2012 a la mode, inc.
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