Reverse Mortgage Quote Proposal Request To pre-review your borrower’s credit and income situation please complete the following form. The requirement of pre-counseling approval is intended to prevent unnecessary counseling and appraisal expenses. Please note that pre-counseling approval is NOT loan approval nor a commitment to lend. Pre-counseling approval is based solely on the information provided and should be used as a tool to communicate with your borrower. Land Home Financial Services can not make a final decision until completing a full review of the complete file. Loan Originator Name* First Last Loan Originator NMLS*Loan Originator Phone*Loan Originator Email* Loan Originator Company Name*Property InformationProperty Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Estimated Market Value of Home*1st Mortgage Balance2nd Mortgage BalanceOther Liens Requiring Payoff at ClosingProperty Type*Single Family Residence2-4 UnitsCondoManufactured HomeManufactured Home - CondoCondo Project Name*FHA Approved Condo*YesNoPower of Attorney?YesNoPOA Status of BorrowerCompetentIncompetentHECM Type*Traditional HECM RefinanceHECM to HECM RefinanceHECM PurchaseOriginal HECM Closed Date*Current Principal Limit*Original Appraisal Value*ON A PURCHASE, SELLER, AGENTS, BROKER OR LENDER CAN OFFER NO CONCESSIONS IN ANY WAY. BUYER MUST PAY THE SELLER’S TITLE, TRANSFER TAX, AND THEIR OWN HOME WARRANTY!How would the borrower(s) like the funds?Cash at ClosingLine of CreditTenure PaymentTerm PaymentOtherIf "Other" is selected, please list below:Cash at Closing AmountTerm YearsTerm AmountClose of EscrowMM/DD/YYYYPurchase Price*Would you like to add an Origination Fee?*YesNoBorrower InformationBorrower Full Name* First Last Borrower DOB*MM/DD/YYYYBorrower's Income*Source of Borrower's Income*Liquid Assets: Total in Checking and Savings*Liquid Assets: RetirementLiquid Assets: OtherIs there a Co-Borrower?*YesNoCo-Borrower InformationCo-Borrower Full Name* First Last Co-Borrower DOB*MM/DD/YYYYCo-Borrower's Income*Source of Co-Borrower's IncomeCo-Borrower's Liquid Assets: Total in Checking and Savings*Co-Borrower's Liquid Assets: RetirementCo-Borrower's Liquid Assets: OtherCar PaymentsAdditional Car Payments?YesNoCar 2 Payments*Credit Card Minimum PaymentsAdditional Credit Card?YesNoCredit Card 2 Minimum Payments*Additional Credit Card?*YesNoCredit Card 3 Minimum Payments*Additional Credit Card?*YesNoCredit Card 4 Minimum Payments*Other Installment PaymentsAdditional Installment Payments?*YesNoOther Installment Payments 2*Cosigned DebtsTax Payment Plan (Monthly)Bankruptcy Payment Plan (Monthly)Extenuating Circumstances for Credit Issues or Major DelinquenciesLoss of Income, Illness, Death, etc.Compensating Factors for Satisfying Residual IncomeNew Job, Benefits Pending, NBS Working, Excess Assets, Available Credit, etc.Non-Borrowing Spouse InformationIs there a Non-Borrowing Spouse?*YesNoNon-Borrowing Spouse's Name* First Last Non-Borrowing Spouse's DOB*MM/DD/YYYYNon-Borrowing Spouse's Income*Is there a Non-Borrowing Household Member?*YesNoNon-Borrowing Household Member's Name* First Last Payment HistoryBankruptcy*YesNoDate of Bankruptcy*MM/DD/YYYYShort Sale / Foreclosure*Short SaleForeclosureNot ApplicableGovernment Short Sale? (FHA, VA, USDA)*YesNoDate of Short Sale*MM/DD/YYYYGovernment Foreclosure? (FHA, VA, USDA)*YesNoDate of Foreclosure*MM/DD/YYYYExtenuating Circumstances for BK, SS, and/or ForeclosureLoss of Income, Illness, Death, etc.Mortgage Lates in the Past 24 Months?*YesNoMortgage Payments Amount*Reason for Mortgage Lates*Late Property Tax Payment in Past 24 Months?*YesNoProperty Tax Payments Amount*Reason for Late Property Tax Payment(s)*Lapse of Homeowner's Insurance in Past 12 Months?*YesNo/Not ApplicableHomeowner's Insurance Premium*Late Homeowner's Insurance Payment in Past 24 Months?*YesNoReason for Late Homeowner's Insurance Payment(s)*Flood Insurance?*YesNo/Not ApplicableFlood Insurance Payments Amount*Homeowners Association?*YesNoHOA Dues Amount*Late HOA Payment in Past 24 Months?*YesNoAdditional InformationPlease enter any notes here.PhoneThis field is for validation purposes and should be left unchanged.