NOTE: You do not need to fill out the darker shaded areas unless you have a co-borrower.

I. TYPE OF MORTGAGE AND TERMS OF LOAN
Mortgage Inquiry for: Conventional   Refinancing First Mortgage   First Time Buyer Second Mortgage   New Construction Home Equity   Inquiry	Loan Amount Sales Price/Value Interest Rate % No of Months Amortization Type Fixed Rate ARM (specify)
II. PROPERTY INFORMATION AND PURPOSE OF LOAN
Subject Property Address: Address   City State Zip # of Units If Applicable, are you currently working with a realtor? Yes    Realtor: No
III. BORROWER(S) INFORMATION
Borrower Information: (include suffix (Jr., Sr.) if applicable)   Prefix First Name Last Name Suffix Home Phone Marital Status Married Separated Unmarried Age Date of Birth (MM/DD/YYYY) Social Security Number Physical Address   Mailing Address   City State IL IA Zip Ownership Status Own Rent No. of years E-mail:	Co-Borrower Information: (include suffix (Jr., Sr.) if applicable)   Prefix First Name Last Name Suffix Home Phone Marital Status Married Separated Unmarried Age Date of Birth (MM/DD/YYYY) Social Security Number Physical Address   Mailing Address   City State Zip Ownership Status Own Rent No. of years Email:
IV. EMPLOYMENT INFORMATION
Borrower Employment:   Check if self-employed Name of Employer Address   City State ZIP Phone Type of Business Position/Title Years on the job Years in Profession	Co-Borrower Employment:   Check if self-employed Name of Employer Address   City State ZIP Phone Type of Business Position/Title Years on the job Years in Profession
V. MONTHLY INCOME AND COMBINED HOUSING EXPENSE INFORMATION
Gross Monthly Income:   Borrower $ Co-Borrower $ Note: Self-employed borrower(s) may be required to provide additional documentation such as tax returns and financial statements Other Income: Notice: Alimony, child support, or separate maintenance income need not be revealed if the Borrower (B) or Co-Borrower (C) does not choose to have it considered for for repaying this loan. Alimony: (B) Alimony: (C) Child Support: (B) Child Support: (C) Separate Maintenance: (B) Separate Maintenance: (C) Other: (B) Other: (C) $ Alimony: (B) Alimony: (C) Child Support: (B) Child Support: (C) Separate Maintenance: (B) Separate Maintenance: (C) Other: (B) Other: (C) $ Alimony: (B) Alimony: (C) Child Support: (B) Child Support: (C) Separate Maintenance: (B) Separate Maintenance: (C) Other: (B) Other: (C) $ Total Monthly Income:      $	Monthly Expenses:   Rent $ 1st Mortgage (P&I) $ Other Financing (P&I) $ Hazard Insurance $ Real-Estate Taxes $ Mortgage Insurance $ Homeowner's Assn. $ Other Expenses (please list) $ $ $ TOTAL: $
VI. ASSETS AND LIABILITIES
Total Assets: Please list all assets, including checking and savings accounts, money market, stocks and bonds and real estate. Exclude any retirement funds. If you need more space, combine accounts, or use "Other." Checking $ Savings $ Money Market $ CDs $ Stocks $ Bonds $ Real Estate $ Other: $ $ $ $ $     TOTAL: $	Total Liabilities: Please list all bank loans, credit card balances, finance companies and credit unions. Also include alimony, child support and separation agreements. Bank Loan Balance $ Credit Card Balance $ Credit Card Balance $ Credit Card Balance $ Finance Company Balance $ Credit Union Balance $ Monthly Alimony $ Monthly Child Support $ Monthly Separation Agmt $ Other: $ $ $ $ $     TOTAL: $
VII. Information For Government Monitoring Purposes
The following information is requested by the Federal Government for certain types of loans related to a dwelling, in order to monitor the Lender's compliance with equal credit opportunity, fair housing and home mortgage disclosure laws. You are not required to furnish this information, but are encouraged to do so. The law provides that a Lender may neither discriminate on the basis of this information , nor on whether you choose to furnish it. If you furnish the information, please provide both ethnicity and race. For race, you may check more than one desgination. If you do not furnish ethnicity, race, or sex, under Federal regulartions, this lender is required to note the information on the basis of visual observation or surname. If you do not wish to furnish the information, please check the box below. (Lender must review the above material to assure that the disclosures satisfy all requirements to which the Lender is subject under applicable state law for the particular type of loan applied for.)
Borrower I do not wish to furnish this information. Ethnicity: Hispanic or Latino   Not Hispanic or Latino     Race American Indian or Alaskan Native   Native Hawaiian or Other Pacific Islander   Black or African American   White   Asian     Sex Female   Male	Co-Borrower I do not wish to furnish this information. Ethnicity: Hispanic or Latino   Not Hispanic or Latino     Race American Indian or Alaskan Native   Native Hawaiian or Other Pacific Islander   Black or African American   White   Asian     Sex Female   Male
VIII. Comments and Questions
When you submit this form, your request will be forwarded to a Marine Bank Loan Representative. After you have received your pre-approval, contact us at the Loan Department to schedule an appointment or call us at (217) 357-3151 to discuss the next steps in the mortgage process for you. Everything that I/we have stated in this application is correct to the best of my/our knowledge. I/ we understand that you will retain this application whether or not it is approved, you are authorized to check my/our credit and my/our employment history and to answer questions about your credit experience with me/us.

As required by the
USA PATRIOT ACT
Important information about procedures for opening a new account

To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.

What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you.

We may also ask to see your driver's license or other identifying documents.

Marine Bank & Trust thanks you for your understanding for joining us in securing a safer tomorrow.