Mortgage Application

Mortgage Loan Application

Contact the Citizens Bank of Kansas Mortgage Lending expert in your area:

Tom Wagner, NMLS# 458607

West Wichita 316.729.8800

Ben Drouhard, NMLS # 458605

East Wichita 316.684.2265

Monty Applebee, NMLS# 458612

Rural Development Specialist

785.445.5164

Courtney Hardgrave, NMLS# 1002678

Kingman 620.532.5162

Teresa Bradbury, NMLS# 458610

Winfield 620.221.4230

Debbie Winter, NMLS# 926481

Medicine Lodge 620.886.5686

Mortgage Application

Please complete all boxes and fields below. APPLICANT #1 * indicates required fields
FULL NAME (First Middle Last)	SOCIAL SECURITY #
* * First Name is required Last Name is required	* Social Security Number is required
WORK PHONE # HOME PHONE #	EMAIL ADDRESS
* Home Phone Number is required	* Email Address is required
DATE OF BIRTH	YEARS OF SCHOOL COMPLETED
* Date of Birth is required
MARITAL STATUS	# OF DEPENDENTS AGES
* Marital Status is required	* Number of dependents is required
HOME ADDRESS
* Current address required
CITY STATE ZIP
* Current city required,* Current state required* Current zip required
YEARS AT PRESENT ADDRESS	CURRENT RESIDENTIAL STATUS
* Years at present address is required	* Current Residential Status is required

PREVIOUS ADDRESS (If less than 2 years at present address)

CITY STATE ZIP
,
PREVIOUS RESIDENTIAL STATUS	YEARS AT PREVIOUS ADDRESS

PRESENT EMPLOYER NAME	SELF EMPLOYED PERCENT OF BUSINESS OWNED
* Present Employer Name is required	YES
TYPE OF BUSINESS	YEARS IN THIS TYPE OF WORK

EMPLOYER ADDRESS
* Employer Address is required
CITY STATE ZIP
* Employer City is required , * Employer State is required * Employer Zip is required
POSITION/TITLE	YEARS IN THIS POSITION
* Position is required	* Years in this Position is required
PHONE NUMBER
* Phone Number is required
GROSS MONTHLY SALARY
* Gross Monthly Salary is required

PREVIOUS EMPLOYER (If less than 2 years with present employer)	SELF EMPLOYED PERCENT OF BUSINESS OWNED
	YES
TYPE OF BUSINESS	YEARS IN THIS TYPE OF WORK

EMPLOYER ADDRESS

CITY STATE ZIP
,
POSITION/TITLE	YEARS IN THIS POSITION

PHONE NUMBER

GROSS MONTHLY SALARY

OTHER INCOME (alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.)
SOURCE	MONTHLY AMOUNT

If you answer "Yes" to any questions a through i, please provide an explanation.

a. Are there any outstanding judgments against you?

YES

N/A *

Explanation

b. Have you been declared bankrupt within the past seven years?

YES

N/A *

Explanation

c. Have you had property foreclosed upon or given title or deed in lieu thereof in the last seven years?

YES

N/A *

Explanation

d. Are you a party to a lawsuit?

YES

N/A *

Explanation

e. Have you directly or indirectly been obligated on any loan which resulted in foreclosure, transfer of title in lieu of foreclosure, or judgment? (This would include such loans as home mortgage loans, SBA loans, home improvement loans, educational loans, manufactured (mobile) home loans, any mortgage, financial obligation, bond or loan guarantee.) If "Yes," provide details, including date, name and address of Lender, FHA or VA case number (if any), and reasons for action.

YES

N/A *

Explanation

f. Are you presently delinquent or in default on any Federal debt or any other loan, mortgage, financial obligation, bond or loan guarantee? If "Yes," give details as described in the preceding question.

YES

N/A *

Explanation

g. Are you obligated to pay alimony, child support or separate maintenance?

YES

N/A *

Explanation

h. Is any part of the down payment borrowed?

YES

N/A *

Explanation

i. Are you a co-maker or endorser on a note?

YES

N/A *

Explanation

j. Citizenship?

k. Have you had an ownership interest in a property in the last three years?

YES

N/A *

1) What type of property did you own-- principal residence, second home or investment property?

2) How did you hold title to the home-- solely by yourself, jointly with your spouse or jointly with another person?

The following information is requested by the Federal Government for certain types of loans related to a dwelling in order to monitor the lender's compliance with equal credit opportunity, fair housing and home mortgage disclosure laws. You are not required to furnish this information, but are encouraged to do so. The law provides that a lender may not discriminate either on the basis of this information, or on whether you choose to furnish it. If you furnish the information, please provide both ethnicity and race. For race, you may choose more than one designation. If you do not furnish ethnicity, race or sex, under Federal regulations the lender is required to note the information on the basis of visual observation and surname if you have made this application in person. If you do not wish to furnish the information, please indicate your choice by checking the box provided.

I do not wish to furnish this information.

l. Ethnicity

m. Race

Additional Race

n. Sex

APPLICANT #2
WE INTEND TO APPLY FOR JOINT CREDIT

FULL NAME (First Middle Last)

SOCIAL SECURITY #

WORK PHONE # HOME PHONE #

EMAIL ADDRESS

DATE OF BIRTH

YEARS OF SCHOOL COMPLETED

MARITAL STATUS

# OF DEPENDENTS AGES

HOME ADDRESS

CITY STATE ZIP

YEARS AT PRESENT ADDRESS

CURRENT RESIDENTIAL STATUS

PREVIOUS ADDRESS (If less than 2 years at present address)

CITY STATE ZIP
,
PREVIOUS RESIDENTIAL STATUS	YEARS AT PREVIOUS ADDRESS

PRESENT EMPLOYER NAME	SELF EMPLOYED PERCENT OF BUSINESS OWNED
	YES
TYPE OF BUSINESS	YEARS IN THIS TYPE OF WORK

EMPLOYER ADDRESS

CITY STATE ZIP
,
POSITION/TITLE	YEARS IN THIS POSITION

PHONE NUMBER

GROSS MONTHLY SALARY

PREVIOUS EMPLOYER (If less than 2 years with present employer)	SELF EMPLOYED PERCENT OF BUSINESS OWNED
	YES
TYPE OF BUSINESS	YEARS IN THIS TYPE OF WORK

EMPLOYER ADDRESS

CITY STATE ZIP
,
POSITION/TITLE	YEARS IN THIS POSITION

PHONE NUMBER

GROSS MONTHLY SALARY

OTHER INCOME (alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.)
SOURCE	MONTHLY AMOUNT

If you answer "Yes" to any questions a through i, please provide an explanation.

a. Are there any outstanding judgments against you?

YES

N/A

Explanation

b. Have you been declared bankrupt within the past seven years?

YES

N/A

Explanation

c. Have you had property foreclosed upon or given title or deed in lieu thereof in the last seven years?

YES

N/A

Explanation

d. Are you a party to a lawsuit?

YES

N/A

Explanation

YES

N/A

Explanation

YES

N/A

Explanation

g. Are you obligated to pay alimony, child support or separate maintenance?

YES

N/A

Explanation

h. Is any part of the down payment borrowed?

YES

N/A

Explanation

i. Are you a co-maker or endorser on a note?

YES

N/A

Explanation

j. Citizenship?

k. Have you had an ownership interest in a property in the last three years?

YES

N/A

1) What type of property did you own-- principal residence, second home or investment property?

2) How did you hold title to the home-- solely by yourself, jointly with your spouse or jointly with another person?

I do not wish to furnish this information.

l. Ethnicity

m. Race

Additional Race

n. Sex

LOAN/PROPERTY INFORMATION
PURPOSE OF LOAN

Purchase

Refinance *

DOWN PAYMENT AVAILABLE

LOAN AMOUNT REQUESTED

PROPERTY USE

PRESENT MONTHLY HOUSING RENT	FIRST MORTGAGE

ASSETS
This Statement and any applicable supporting schedules may be completed jointly by both married and unmarried Co-Borrowers if their assets and liabilities are sufficiently joined so that the Statement can be meaningfully and fairly presented on a combined basis; otherwise, separate Statements and Schedules are required. If the Co-Borrower section was completed about a spouse or other person, this Statement and supporting schedules must be completed about that spouse or other person also.
ACCOUNT TYPE
* Account Type is required
INSTITUTION (include banks, credit unions, S&Ls, etc.)
* Institution Name is required
ADDRESS

CITY STATE ZIP
,
ACCOUNT #	BALANCE
	* Balance is required

ACCOUNT TYPE

INSTITUTION (include banks, credit unions, S&Ls, etc.)

ADDRESS

CITY STATE ZIP
,
ACCOUNT #	BALANCE

OTHER ASSETS
CASH VALUE STOCKS, BONDS, SECURITIES	COMPANY

GIFT

CASH VALUE OF LIFE INSURANCE (if source of down payment)

RETIREMENT FUNDS (vested)

OTHER (if source of down payment)	DESCRIPTION

REAL ESTATE OWNED
ADDRESS #1

CITY STATE ZIP
,
PROPERTY TYPE

PRESENT MARKET VALUE	GROSS RENTAL INCOME

ADDRESS #2

CITY STATE ZIP
,
PROPERTY TYPE

PRESENT MARKET VALUE	GROSS RENTAL INCOME

I/We have applied for credit from the Lender. As part of the application process, the Lender and any potential investor or insurer of this loan may verify the information contained in my/our credit application and in other documents required in connection with this loan.

I/We authorize you to provide to the Lender and to any potential investor or insurer of this loan, any and all information and documentation requested. Such information may include, but is not limited to: employment and income history, bank, money market and similar account balances; credit history; and copies of income tax returns. The source of the information may come from, but is not limited to: credit bureaus; banks and other depository institutions; current and former employers; federal or state records including State Employment Security Agency (SESA) records; or other sources as required.

This authorization to access employment and income history from federal or state records including SESA records, for this transaction continues in effect for one (1) year unless limited by state law, in which case the authorization continues in effect for the maximum period, not to exceed one (1) year, allowed by law.

Certification: I/We certify that the information provided in this application is true and correct as of the date submitted by clicking "Submit Application" below. I/we acknowledge my/our understanding that any intentional or negligent misrepresentation(s) of the information contained in this application may result in civil liability and/or criminal penalties including, but not limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Section 1001, et seq. and liability for monetary damages to the Lender, its agents, successors and assigns, insurers and any other person who may suffer any loss due to reliance upon any misrepresentations which I/We have made on this application.