Application

Primary Account Owner

*Name (First M. Last)
*Date of Birth (mm/dd/yyyy)
*Social Security Number
*Address
*City, State Zip ,
*Home Phone Number
Work Phone Number
*Driver's License Number *State
E-mail

* indicates a required field

Mortgage Information

Please Select One Purchase Refinance
If Refinance, Cash Out? Yes No
Term Requested Thirty Year   Twenty Year
  Fifteen Year Ten Year

Optional Information

To further assist in pre-qualification, please provide the following optional information
(Please do not use commas or dollar signs in any answer):

Gross Income $ (Borrower)
  $ (Co-Borrower)
Total Revolving Debt $ per month
Total Installment Debt $ per month
Value/Sales Price of Property $ per month
Loan Amount $ per month

Taxpayer Identification Number Certification

The Social Security Number(s) shown above is my correct SSN.
I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding.
I am an exempt recipient under the Internal Revenue Service Regulations.
I am not a United States person, or if I am an individual, I am neither a citizen nor a resident of the United States.
I certify under penalties of perjury the statements checked in this section are true.
I authorize Security Savings Bank to obtain a copy of my current credit report as a condition of acceptance of this application and for the purpose of extension of or renewal of credit.
* indicates a required field