This form is divided into the following sections:

• Mortgage amount and repayment period
• Salary, employment and status details
• Details of home ownership and mortgage
• Form Submission

Please key in the data requested or select one of the options :-

Purpose of Mortgage ?

Mortgage Amount (£) ?

Mortgage Period (months) ? 60 84 96 120 144 180 240 300

Capital Repayment or Interest Only ? Capital Repayment Interest Only

Fixed Rate or Variable Rate ? Fixed Rate Variable Rate

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Salary, Employment and Status Details

Gross Annual Income (£) ? Partner's Annual Income (£) ?

How long in job (years) ? How long partner in job (years) ?

Applicant's date of birth ? Partner's date of birth ?

Applicant Employment Status ? Employed Self employed

Partner Employment Status ? Employed Self employed

Number of County Court Judgements registered within last 5 years (unsatisfied) ?

Total value of unsatisfied County Court Judgements ?

Number of County Court Judgements registered within last 5 years (satisfied) ?

Total value of the satisfied County Court Judgements ?

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Details of Home Ownership and Mortgage

Date Property Purchased ?

Purchase Price of Property ?

Value of Property (£) ?

Mortgage Balance Outstanding (£) ?

Other Outgoings - endowment etc. (£) ?

How long in present house (months) ?

Do you have a current secured loan or second mortgage ? Yes No

If so, amount owed (£) ?

Current Mortgage Arrears (months) ?

Highest Mortgage Arrears within last 12 months (months) ?

Main Residence ? Yes No

Council House Purchase ? Yes No

Freehold ? Yes No

Mortgage Payment Per Month ?

Mortgage Company Name ?

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FORM SUBMISSION

Thank you for taking the time to answer the above questions.

Please now complete the following details:

Applicant's Full Name

Partner's Full Name

Address Line 1

Address Line 2

Address Line 3

Address Line 4

Post Code

Home Phone Number

Work Phone Number

Email Address