Your Family Bank Debt Questionnaire

Personal Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Birth Date*

MonthDayYear
Sex*
Spouse Name

First NameLast Name
Birth Date

MonthDayYear
Sex
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who were you referred by First Name* Last Name*

Real Estate

PERSONAL RESIDENCE
Mortgage Payment (P&I only)
eg. $1,167.53
Outstanding Mortgage Balance
eg. $197,785.97
Term Remaining (years)
eg. 26 years
Type of Mortgage

Fixed TermARMInterest Only
Mortgage Term (years)
for Fixed Term 15, 30 year etc, for ARM 5, 7, 10 year etc.
Real Estate

OTHER PROPERTY OWNED
Mortgage Payment (P&I only)
eg. $1,167.53
Outstanding Mortgage Balance
eg. $197,785.97
Term Remaining (years)
eg. 26 years
Interest Rate (%)
eg. 6.2%
Type of Mortgage

Fixed TermARMInterest Only
Mortgage Term (years)
for Fixed Term 15, 30 year etc... for ARM 5, 7, 10 year etc.

Debt Related

Please list any and all outstanding debts other than your mortgages.
name of debt amount owed ($) interest rate (%) minimum payment ($) Actual Payment ($)
name of debt amount owed ($) interest rate (%) minimum payment ($) Actual Payment ($)
name of debt amount owed ($) interest rate (%) minimum payment ($) Actual Payment ($)
name of debt amount owed ($) interest rate (%) minimum payment ($) Actual Payment ($)
name of debt amount owed ($) interest rate (%) minimum payment ($) Actual Payment ($)
name of debt amount owed ($) interest rate (%) minimum payment ($) Actual Payment ($)
name of debt amount owed ($) interest rate (%) minimum payment ($) Actual Payment ($)
name of debt amount owed ($) interest rate (%) minimum payment ($) Actual Payment ($)
name of debt amount owed ($) interest rate (%) minimum payment ($) Actual Payment ($)
name of debt amount owed ($) interest rate (%) minimum payment ($) Actual Payment ($)
name of debt amount owed ($) interest rate (%) minimum payment ($) Actual Payment ($)
name of debt amount owed ($) interest rate (%) minimum payment ($) Actual Payment ($)
name of debt amount owed ($) interest rate (%) minimum payment ($) Actual Payment ($)
name of debt amount owed ($) interest rate (%) minimum payment ($) Actual Payment ($)
name of debt amount owed ($) interest rate (%) minimum payment ($) Actual Payment ($)
name of debt amount owed ($) interest rate (%) minimum payment ($) Actual Payment ($)
name of debt amount owed ($) interest rate (%) minimum payment ($) Actual Payment ($)
name of debt amount owed ($) interest rate (%) minimum payment ($) Actual Payment ($)
Should be Empty:

Personal Information

Real Estate

Real Estate

Debt Related