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  |   Your Full Name |   * | 
 |   Address |    * | 
 |   City |    * | 
 |   State(USA Only) |    AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY  * UNITED STATES ONLY! | 
 |   Zip/Postal Code |   * | 
|   Home Phone |    * | 
 |   Work Phone |   * | 
 |   Email Address |   * | 
 |   Best Time To Call |   Morning at Home Morning at Work Afternoon at Home Afternoon at Work Evening at Home Late Evening at Home  * | 
 |   Do You Own Your Home? |   Yes No  * Mobile Homes Do Not Qualify | 
 |   Property Value |  = 50000)) { alert('Not Valid! Please enter the approximate value of current property or property you wish to purchase \n (greater than or equal to 50000) using only number characters - 0123456789'); this.focus(); this.select(); return false; }"> * Please use numbers only | 
 |  Property Type |    Single Family Residence Condo Townhouse 2-4 Plex Other  * | 
 |   Purchase Price |   * Please use numbers only | 
 |    Year Acquired  |   * | 
 |  1st Mortgage-Balance Owed |    * Please use numbers only (ex:45000) enter 0 for none | 
  |  1st Mortgage-Interest Rate |    10 or above Below 7.0 7.1 - 7.49 7.5 - 7.998.0 - 8.49 8.5 - 8.99 9.0 - 9.49 9.5 - 9.99 None  % | 
|   Is 1st Adjustable or Fixed? |   Fixed Adjustable  * | 
  |  Employer |    * | 
|   Monthly Gross Household Income |   * Please use numbers only | 
  |   2nd Mortgage Balance owed |  > * Please use numbers only(ex:45000) enter 0 for none | 
 |  Amount You Wish To Borrow |    15,000 - 30,000 30,000 - 45,000 45,000 - 60,000 60,000 - 75,000 75,000 - 90,000 90,000 - 110,000 110,000 - 125,000 125,000 & Up  * | 
 |   Credit Rating |   Good Fair Poor Excellent  * | 
 |   Monthly Debt |   * Please use numbers only | 
 |   Loan Interested In |   Debt Consolidation Second Mortgage Home Improvement Refinance Purchase  *   | 
 Fast & Easy -You Are Done !    |