date of birth

social security number

address

city

state

zip code

e-mail address

phone number

how long at residence

Own   rent

# of years employed

salary

work phone number

# of years employed

date of birth

social security number

# of years employed

salary

mortgage balance

2nd mortgage bal.

vehicle loan amount

vehicle loan #2 amount

credit card #1 balance

credit card #2 balance

monthly 2nd mortgage payment

monthly vehicle payment

monthly vehicle #2 payment

credit card #1 payment

credit card #2 payment

Have you ever filed for bankruptcy?  No   Yes

Have you ever had property repossessed?  No   Yes