Reverse Mortgage Intake Form

Reverse Mortgage Intake Form
MLO Name*
Subject Property State*
Referral/Intake Selection*
Property Address*
Estimated Home Value*
Approx. Balance of All Mortgages*
How Many Borrowers?
Borrower Name*
Co-Borrower Name*
Borrower Date of Birth*

MonthDayYear
Co-Borrower Date of Birth*

MonthDayYear
Best Phone Number*
Best Email Address*
Notes (Goals, Needs, and Desires)*
Please note that Reverse Mortgage origination activities must be completed by the MLO who is licensed in [{subjectProperty}].
- Send It & Forget It: [{mloName}] agrees give a warm introduction via email or phone between the borrower & Brian Bailey. Brian will work the file as needed through to Closing.
- Assist It Deals: [{mloName}] agrees to jointly work the file with Brian Bailey, taking notes, and providing support as instructed.
- Mentorship Deals: [{mloName}] agrees to jointly work the file with Brian Bailey, providing support as instructed.
- Solo Deals: [{mloName}] confirms that certification has been completed, and [{mloName}] is fully capable of working the file through to closing.
By submitting this form, you are confirming you acknowledge the above.
Should be Empty: