MORTGAGE PREQUALIFICATION WORKSHEET 4320 Linglestown Road, Harrisburg PA 17112 717.657.7727 | CentricBank.com 1 | BORROWER’S PERSONAL INFORMATION Last Name First Name Middle Initial City State Zip Home Phone Cell Phone Work Phone Email Social Security No. Birthdate (MM/DD/YYYY) Home Address 2 | BORROWER’S EMPLOYMENT INFORMATION Employer Full Time: Position Hourly Years Employed Gross Monthly Income Yes No Salary Commission Other Income* * Do not reveal income from alimony, child support, or separate maintance payments unless you are relying on such income to repay this account. 3 | CO-BORROWER’S PERSONAL INFORMATION Last Name First Name Middle Initial City State Zip Home Phone Cell Phone Work Phone Email Social Security No. Birthdate (MM/DD/YYYY) Home Address 4 | CO-BORROWER’S EMPLOYMENT INFORMATION Employer Full Time: Position Hourly Years Employed Gross Monthly Income Yes No Salary Commission Other Income* * Do not reveal income from alimony, child support, or separate maintance payments unless you are relying on such income to repay this account. 5 | CREDIT AUTHORIZATION By signing below, I authorize Centric Bank to obtain my credit report. I also authorize Centric Bank to provide my credit report to any affiliate of Centric Bank for their review. I understand that if I have any questions, disputes, or comments about the information on my credit report, I must contact the credit reporting agency to address these issues. This authorization is not an application for credit, nor is it a request to Centric Bank to consider an application from me for credit. Borrower’s Signature Date Co-Borrower’s Signature Save the completed worksheet to your computer and submit to: • Postal Mail - P.O. Box 62090, Harrisburg PA 17106-2090; Attn: Getty Wilson Thank you! We will contact you within 48 hours of receiving your completed worksheet. GETTY WILSON, NMLS 586367 Vice President, Mortgage Department Manager P: 717 909 8302 | E: [email protected] |1| Date