Loan Application

Qualification:

• Total of all the taxes, penalties and fees you owe the taxing authority must be at least $2500
• Borrowers cannot currently be involved in an open bankruptcy case.

Comments or questions are welcome.

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Name:*

E-Mail Address:*

Property Information

Property Address

City

State

Zip Code

County

Est. Tax Amount Due

Requested Loan Term:

3years 5years 7years Others

Mortgage Information

Mortgage Company

If none, enter "None"

Mortgage Balance

Monthly Payment

Borrower Information

Mailing address

Mailing City

Mailing State

Mailing Zip Code

Social Security Number

Date of Birth

Marital Status:

Married Single Separated Other

I prefer to be called at:

Home Office Cell

Best time to call me:

Morning Afternoon Evening

Phone number to call you on

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