PYWS-Intake-Form

Lender Questionnaire

GLC [Qualified Funds]
Name*

Lender First NameLender Last Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Spouse's Full Name
(Optional)
Amount to loan?*
In USD
Source of Funds*
Who is your checkbook IRA custodian?*
Do you have checkbook control? (Only check "Yes" if your funds are held in a checking account under an LLC. If the custodian is sending the funds, mark "No".)*

YesNo
Lender Business Name
(Only complete this field if you have an LLC with a Checkbook IRA)
Please Select Your Advanta Rep*

Jorge Diaz (jdiaz@advantaira.com)Larissa Greene (lgreene@advantaira.com)Hannah Harrison (hharrison@advantaira.com)Other Agent
Advanta Account #*
If you have checkbook control with a custodian OTHER than Advanta IRA, enter N/A here
Duration of Note*
Please select the option you prefer
Advanta Rep Email*
example@example.com
Vesting/Titling*
Please verify with your custodian how the loan should be titled
Special Notes
Any additional information you would like to provide
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Should be Empty:

Lender Questionnaire