| Applicant Information |
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Are you a Us Citizen? |
| First Name MI: * |
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| Last Name: * |
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| Social Security #: * |
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| Date of Birth:: * |
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| Gender: |
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| Marital Status:: |
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| Address Street 1: * |
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| Address Street 2: |
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| City: * |
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| Zip Code: * |
(5 digits) |
| State: * |
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| Rent or Own?: * |
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| How long at resisdence?: * |
(in years) |
| Employer Name, Address & Phone #:: * |
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| How long on job?: |
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| Gross Monthly Income:: * |
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| Other Income:: |
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| Co-Applicant Information |
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Are you a US Citizen? |
| First Name MI: |
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| Last Name: |
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| Social Security #: |
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| Date of Birth: |
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| Gender: |
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| Marital Status:: |
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| Address Street 1: |
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| Address Street 2: |
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| City: |
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| Zip Code: |
(5 Digits) |
| State: |
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| How long at resisdence?: |
(in years) |
| Employer Name, Address & Phone #:: |
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| How long on job?: |
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| Gross Monthly Income:: |
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| Other Income:: |
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| Contact Information |
| Daytime Phone: * |
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| Evening Phone: |
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| Email: |
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| Financial Information |
| Loan Type: |
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| Loan Amount: |
(USD) |
| Property Information |
| Property Type: |
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| Occupancy: |
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| Do you own land?: * |
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| Are you?: |
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| Purchase Price: |
(USD) |
| Amount owed on land:: |
(USD) |
| Appraised Value: |
(USD) |
| Mortgage Balance: |
(USD if applicable) |
| Other Information |
| Assets: * |
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| List Monthly Payments of all Debts:: * |
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I authorize Infinity Homes of Jax, Inc and it's preferred lender(s) to verify my credit and employment history. This box is checked in lieu of my signature. |