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* Full Name * Phone * Email Company Name

* Address * City

State

Zip

Role

* Borrower Name * Subject Property * Address * City

State

Zip

Requested Loan Amount

Borrower Type

Estimated Value

Approx Balance Owing

Additional Collateral Property Type (if applicable) Collateral Address

Loan Purpose Subject Property Use Purchase date

Purchase price Subordinate financing amount

Loan Purpose Subject Property Use Current value

Completion value Land cost Construction cost Subordinate financing amount(if any)

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