Please fill out the information below and we will contact you within 24 hours with specific information about your mortgage loan options. Customer Information:   First Name Last Name Address Line 1 Address Line 2 City State Zip Code Daytime Phone ( ) - Evening Phone ( ) - E-mail Address Loan & Property Information:   Loan Purpose Approximate Home Value Credit Rating (Excellent, Good, Fair, Poor) Current Interest Rate Loan Amount Desired First Mortgage Balance Type of Home (SFR, Condo, Townhouse, 2-4 Plex) Rate Type (Fixed or Adjustable) Comments

United Capital Mortgage Solutions, Inc. • NMLS#270987 • Laguna Beach, CA 92651-7605 • (949) 290-3831

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