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Note: This form is for pre-qualification purposes only. This is not a formal application. A representative of Pioneer Bank will contact you to complete the necessary paperwork to continue with the application process.

General Information
Amount Requested
Estimated House Value
Mortgage Balance
Other loan balance(s) where your primary residence is the collateral
How Were You Referred

 

Borrower Information
Borrower - Complete Column # 1 Co-Borrower - Complete Column # 2
Email Address
Email Address
First Name
First Name
Middle Initial
Middle Initial
Last Name
Last Name
Current Address
Current Address
City, State, Zip
City, State, Zip
Daytime Phone Number
Daytime Phone Number
Evening Phone Number
Evening Phone Number

 

Employment Information
Borrower - Complete Column # 1 Co-Borrower - Complete Column # 2
Self-Employed Yes No Self-Employed Yes No
Place of Employment
Place of Employment
Length of time with this Employer (in years)
Length of time with this Employer (in years)
Annual Gross Income
Annual Gross Income
Note: Alimony, child support, or separate maintenance income need not be revealed if you do not wish it to be considered as a basis for repaying this obligation.
Other Sources of Income Other Sources of Income
Amount
Amount
Source
Source

 

Assets
Borrower - Complete Column # 1 Co-Borrower - Complete Column # 2
Checking
Checking
Savings
Savings
401k
401k
CD
CD
Gifts
Gifts
Sale of Real Estate
Sale of Real Estate
Other
Other

 

Credit Information
Borrower - Complete Column # 1 Co-Borrower - Complete Column # 2
Monthly Mortgage Payment
Monthly Mortgage Payment
Other Loans/Credit Cards Other Loans/Credit Cards
Company 1
Company 1
Account #
Account #
Balance
Balance
Minimum Monthly Payment
Minimum Monthly Payment
Company 2
Company 2
Account #
Account #
Balance
Balance
Minimum Monthly Payment
Minimum Monthly Payment
Company 3
Company 3
Account #
Account #
Balance
Balance
Minimum Monthly Payment
Minimum Monthly Payment
Company 4
Company 4
Account #
Account #
Balance
Balance
Minimum Monthly Payment
Minimum Monthly Payment
Company 5
Company 5
Account #
Account #
Balance
Balance
Minimum Monthly Payment
Minimum Monthly Payment
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