Reverse Mortgage Quote Request – The Rate Update
Share your details and home information so Dan Frio can prepare a personalized HECM and proprietary quote.
About You
Do not enter your Social Security number — we will never ask for it on this form.
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Best Time to Call
Please Select
Morning
Afternoon
Evening
Anytime
Marital Status
Please Select
Married
Unmarried
Separated
Widowed
Spouse / Co-Borrower
Is there a spouse or co-borrower?
*
Yes
No
Spouse / Co-borrower full name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Will this person be on the loan?
Please Select
Yes
No – non-borrowing spouse
Not sure
Property
Property Street Address
*
City
*
State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
ZIP Code
*
County
Property Type
*
Please Select
Single-family home
Condo
Townhouse
2-4 unit (I live in one unit)
Manufactured home
Other
Is this your primary residence where you live most of the year?
*
Yes
No
Estimated Home Value
*
Years Lived in Home
Existing Debt on the Home
Do you have a mortgage or HELOC on this home?
*
Yes
No
Current mortgage balance
HELOC balance
Other liens balance
Monthly mortgage payment
Are property taxes and homeowners insurance current?
*
Yes
No
Not sure
Your Goals
Loan purpose
*
Please Select
Pay off my existing mortgage
Line of credit for future needs
Monthly income
Lump sum cash
Buy a new home with a reverse mortgage (H4P)
Other
Amount of cash needed (if known)
Loan type interest
*
HECM (FHA-insured)
Proprietary / Jumbo reverse
Not sure – show me both
Have you completed HUD reverse mortgage counseling?
*
Yes
No
Not yet
How did you hear about us?
Please Select
YouTube – The Rate Update
Google
Referral
Facebook
Other
Additional notes
lead_source
Schedule Your Consultation
Pick a time for Dan to walk you through your estimate (30 minutes)
*
How would you like to meet?
*
Phone call
Video call (Zoom/Teams)
Consent & Submit
By submitting, I agree that Dan Frio / PBT Bancorp may contact me by phone, text and email at the number and email provided about my inquiry, including by automated means. Consent is not a condition of any purchase. Message and data rates may apply. Reply STOP to opt out.
*
Dan Frio | NMLS #246527 | PBT Bancorp | NMLS #257781 | 524 Main St, Hazard, KY 41701. Equal Housing Lender. This is not a commitment to lend. Reverse mortgage borrowers must remain in the home, maintain the property, and pay property taxes, insurance and HOA dues. Not all applicants will qualify.
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