Reverse Loan Proposal

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Broker Information

Name

Loan Originator Information

Name
Phone
Fax
Email Address
NMLS#

Borrower Information

Name
Date of Birth
Phone Number
Social Security Number (OPTIONAL)

Co-Borrower Information

Name
Date of Birth
Social Security Number (OPTIONAL)

Property Information

Street Address
Address Line 2
City
State
Zip Code
Estimated Value

Product requested:

Fixed	Rate requested	Broker Comp Front or Back	$ Front Comp
Line of Credit	Rate requested	Broker Comp Front or Back	$ Front Comp
Lump Sum	Rate requested	Broker Comp Front or Back	$ Front Comp
Monthly Payments	Rate requested	Broker Comp Front or Back	$ Front Comp
Purchase	Rate requested	Broker Comp Front or Back	$ Front Comp

Select all that apply

Additional Comments

Mortgage Information

First Mortgage

First Mortgage Balance
First Mortgage Holder

Second Mortgage

Second Mortgage Balance
Second Mortgage Holder

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