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Mortgage Qualification Request

The mortgage qualification request requires that you complete the following survey as completely and accurately as possible. Once submitted the information will be e-mailed to our office(s) and we will expedite your request. This information will be kept confidential and will be used for quote purposes only. We look forward to serving you.

Fields marked with a Red asterisk * are required.

Fields marked with a Blue asterisk * , at least 1 of the fields must be filled in.

Contact Information

Borrower Information

* Full Name:

Street:

City:

State: Zip:

Zip:

SSN#:

Age:

Telephone Numbers:

*Home:

*Work:

*Cell:

*EMail:

*Best date and time to be reached in the next 48 hours.

Date:		/
	MM	/	DD

Time:

CoBorrower Information
Full Name:
Street:
City:
State:
Zip:
SSN#:	Age:
Telephone Numbers:
Home:
Work:
*Cell:
EMail:

Employment Information

Borrower Information
Self Employed?	No Yes
Employer:

How Long (Yrs/Mths):	/
Monthly Income:
Overtime:
Bonuses:
Commissions:
Other:

CoBorrower Information
Self Employed?	No Yes
Employer:

How Long (Yrs/Mths):	/
Monthly Income:
Overtime:
Bonuses:
Commissions:
Other:

Assets

Borrower Information
Assets
Checking:
Savings:
CD's/Stocks/Bonds:
401K's/IRA's:
Other:

CoBorrower Information
Assets
Checking:
Savings:
CD's/Stocks/Bonds:
401(K)'s/IRA's:
Other:

Combined Liabilities/Other Obligations

Type	Monthly Payment	Unpaid Balance
Credit Cards:
Auto Loans:
Other Loans:
Child Support:

Property/Loan Information

Property Address
Street:
City:
State:
Zip:

Number of units:
Occupancy type:
Property Value:

Type of Mortgage:
Purpose of Loan:
If "Refinancing", For What Purpose:
If "Other", Explain.

Desired Loan Amount:
Estimated Purchase Price:
Estimated Down Payment:
If "Refinancing", Amount Owed Current Home:
Length of New Loan:
Payment Type:

Additional Considerations/Requests

Please give any additional comments you feel appropriate for this quotation.

Please click on the "Submit Request" button to send us your mortgage pre-qualification request.

Dominion Financial Group, Inc.
5520 Wellesley St., Suite 203
La Mesa, CA 91942
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(619) 644-3545 – Office
(619) 644-3550 – Fax

Securities offered by a Registered Representative of Sammons Securities Company, LLC. Member FINRA / SIPC.

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Mortgage Qualification Request

Contact Information

Borrower Information

CoBorrower Information

Employment Information

Borrower Information

CoBorrower Information

Assets

Borrower Information

CoBorrower Information

Combined Liabilities/Other Obligations

Property/Loan Information

Additional Considerations/Requests