Reverse Application Questionnaire Application Questionnaire Have you completed the Quote Proposal Request form?YesNoThe first step to apply for a Reverse Mortgage is to request a Reverse Mortgage Quote Proposal. Please click here for the Reverse Mortgage Quote Proposal Request form.Do you have a Counseling Certificate?YesNoUpload Counseling Certificate* Drop files here or This form can not be submitted without a Counseling Certificate. For assistance please contact your Account Executive or email Reverse.PreQual@LHFSWholesale.com.* I have uploaded the Borrower Authorization Form. Don't have the Borrower Authorization Form? Get it here: https://wholesale.lhfs.com/download/BorrowerAuthorization.pdfBorrower InformationBorrower Full Name* First Last Borrower SSN*Borrower Phone Number*Citizenship*US CitizenLawful Perm. Resident AlienEthnicity*Hispanic or LatinoNot Hispanic or LatinoNot DisclosedNot ApplicableRace*American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian/Other Pacific IslanderWhiteOtherNot DisclosedNot ApplicableAlternative Contact's InformationFull Name* First Last Phone Number*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Relationship to Borrower*Co-Borrower InformationIs there a Co-Borrower?*YesNoCo-Borrower's Name* First Last Co-Borrower's DOB*MM/DD/YYYYCo-Borrower's SSN*Co-Borrower's Citizenship*US CitizenLawful Perm. Resident AlienCo-Borrower's Ethnicity*Hispanic or LatinoNot Hispanic or LatinoNot DisclosedNot ApplicableCo-Borrower's Race*American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian/Other Pacific IslanderWhiteOtherNon-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 SSN*Non-Borrowing Spouse's Income*Subject Property InformationYear Built*Years of Residence*1st Mortgage Balance2nd Mortgage BalanceOther LiensLiving TrustYesNoPower of Attorney?YesNoPOA Status of BorrowerCompetentIncompetentLoan InformationAmortization TypeAnnual ARM (LIBOR)Monthly ARM (LIBOR)FixedWould you like to add an Origination Fee?*YesNoRate/Margin (%)*HECM Type*Traditional HECM RefinanceHECM to HECM RefinanceHECM PurchaseON 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 PaymentHold down the Ctrl or Cmd key to select multiple options.Cash at Closing AmountTerm YearsTerm AmountLoan Originator InformationLoan Originator Name* First Last Additional InformationPlease enter any notes here. PhoneThis field is for validation purposes and should be left unchanged.