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QUESTIONNAIRE » Property State* Please choose one of the following loans* -- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Please select loan option Refinance Refiance to consolidate bills Refiance with cash-out Purchase Commercial Mixed Use I heard about Power Express Morgage Bankers through* Type of Property* Please select how you heard about us Newspaper Ad/ Magazine Ad Phone Call Referral Billboard TV Ad Direct Mail Email Seminar/Home Show Please select property type Single family residence Condo Co-op Multi Family Second Home Other Overall Mortgage Credit* Overall Consumer Credit* Please select your mortgage credit history I never been 30 days late I have been 30 days late I have been 60 days late I have been more tahn 90 days late I have been foreclosed I do not currently have a mortgage Please select one Excellent Good Fair Poor Name* First Middle Last Co-Borrower First Middle Last Street Address* House # Street Name Unit # City and Zip* City Zip Code Home Phone Work Phone Cell Phone Email Preferred Method to Contact You Preferred Time to Contact You Any Method Home Phone Work Phone Mobile Phone Email Any Time 7 am 8 am 9 am 10 am 11 am 12 pm 1 pm 2 pm 3 pm 4 pm 5 pm 6 pm 7 pm 8 pm 9 pm Gross Monthly Income Value of Your Home $ $ Loan Amount Requested* Home much do you currently owe on your property? $ $ When would you like to complete your loan? Preferred Languages Please select time frame for your loan 2 Weeks 3 Weeks 4 Weeks Other Please select Preferred Languages English Chinese Italian French Russian Hebrew Spanish Other Information You May Wish to Provide

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