Mortgage Prequalification Application

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Mortgage Information

Term Requested

Thirty year Twenty-five year

Twenty year Fifteen year

Primary Account Owner

*Name (First M. Last):

*Date of Birth (mm/dd/yyyy):

*Social Security Number:

*Driver's License Number:

*State:

*E-mail:

*Current Address:

*City:

*State:

*Zip:

*Current Home Phone Number:

*Current Employer:

*Current Job Title:

*Current Work Address:

*City:

*State:

*Zip:

*Current Work Phone Number:

Additional Information

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

Gross Income

(Borrower)

(Co-Borrower)

Total Revolving Debt Payment

per month

Total Installment Debt Payment

per month

Value/Sales Price of Property

per month

*Loan Amount

per month

(payments on existing installment loans)

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 Juniata Valley 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.

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