Confidential Questionnaire
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Fill out form and email to sabina@moneysmart.info
We will contact you if there are any
further questions.
Electronic option:
Please complete the on-line Questionnaire below. Fields marked with * are required. |
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| PERSONAL INFORMATION |
| Consultant |
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Date |
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| *Applicant |
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Co-Applicant |
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| *Address |
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Address |
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| *City |
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| *Province |
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| *Postal Code |
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Postal Code |
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| *SIN |
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SIN |
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| *Date of birth |
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Date of birth |
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| *Phone (home) |
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Phone (home) |
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| Phone (work) |
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Phone (work) |
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| Fax Number |
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Fax Number |
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| *E-mail address |
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E-mail address |
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| Occupation |
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Occupation |
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| Employer |
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Employer |
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| How long employed? |
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How long employed? |
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| *Is this your residence? |
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Is this your residence? |
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| *Is this a revenue property? |
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Is this a revenue property? |
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| *Annual Income (gross) |
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Annual Income (gross) |
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| Other Income (gross) |
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Other Income (gross) |
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| Rental Income (gross) |
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Rental Income (gross) |
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| PROPERTY INFORMATION |
| Date of home purchase |
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*Purchase price of home |
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| *Mtg. Balance at purchase |
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*Open or closed mortgage |
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| *Market value of property |
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*Property taxes annual |
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| Note: Please enter Principal and Interest (P&I) payment only - not PIT (principal, interest, taxes) |
| *1st Mortgage Payment P&I |
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*Taxes incl. in payment, yes or no? |
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| If bi-weekly payments, yes or no? |
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*Insurance incl. in payment, yes or no? |
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| If weekly payments, yes or no? |
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Is semi-monthly payments, yes or no? |
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| Important: Be certain that (yes) appears in the correct boxes above, (no) must appear in all non-applicable boxes. |
| Taxes and insurance should not be entered as part of the mortgage Principal & Interest payment above! |
| *1st mortgage balance |
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2nd mortgage balance |
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| *Interest rate |
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Interest rate 2nd mortgage |
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| *Original amortization |
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2nd mortgage payment |
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| *Years left to pay mortgage |
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2nd original amortization |
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| Renewal Date |
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2nd years left to pay |
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| *Lender 1st mortgage |
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Lender - 2nd mortgage |
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| Mortgage acct.# (1st) |
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Mortgage acct.# (2nd) |
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| *Penalty 1st mortgage |
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Penalty 2nd mortgage |
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| LIABILITIES - DEBTS |
| Lender/Type of debt |
Monthly Payment |
Balance |
Interest Rate |
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| Lines of credit - enter below (if more than two, enter under "Lender Type of debt" above) |
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| *Lump sum requested, yes or no? |
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EPP extra cash flow, yes or no? |
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| Lump sum amount? |
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Cash flow amount requested, yes or no? |
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| CREDIT AND SUPPLEMENTARY PERSONAL INFORMATION |
| Enter individual applicable answers under each name |
Applicant |
Enter individual applicable answers under each name |
Co-Applicant |
| *Credit rating description |
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Credit rating description |
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| *Marital status |
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Marital status |
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| Number of dependents residing in your domicile |
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Number of dependents residing in your domicile |
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| *Ever been bankrupt, yes or no? |
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Ever been bankrupt, yes or no? |
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| If yes, when & discharge date |
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If yes, when & discharge date |
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| Purpose of the Lump Sum |
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| PREVIOUS EMPLOYMENT & ADDRESS DETAILS |
| If either applicant has been on present job less than 3 years,
enter previous job details below: |
| Applicant - employer, location, number of years |
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Co-Applicant - employer, location, number of years |
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| Income previous employer |
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Income previous employer |
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| How long residing at present address? (Years) |
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How long residing at present address? (Years) |
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| Less than 3 years, give full previous address |
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Less than 3 years, give full previous address |
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| PROPERTY DETAILS |
| Date re-financed since purchase |
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Re-financed amount |
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| *Mortgage payments up to date, yes or no? |
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*Any liens/judgements, yes or no? |
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| PERSONAL PRIORITIES |
| *Paying Mtg.: 1st or 2nd priority? |
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*Debt relief: 1st or 2nd priority? |
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| PROPERTY PARTICULARS |
| Year property was built |
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Construction |
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| *Detached home, yes or no? |
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*Semi-detached home, yes or no? |
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| Lot size: dimensions in feet |
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Home size: square footage |
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| Number of story's |
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Type of heating |
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| Total rooms in house (all rooms) |
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*Owner occupied, yes or no? |
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| Number of bedrooms |
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Number of bathrooms |
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| Finished basement |
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Family rooms |
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| Garage (Attached or Detached?) |
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Number of cars? |
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| Town House or Condo |
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Condo fees (monthly) |
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| Number of fireplaces |
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Additions made since purchase |
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| Multi-unit or Apt. building |
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No. units/apartments |
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| Description of property |
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Swimming pool, yes or no? |
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| Address mortgaged property |
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| *Mortgage previously CMHC insured, yes or no? |
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If yes, provide CMHC reference number |
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| *Is this a rural property, yes or no? |
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Well & Septic or Serviced? |
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| Type asset |
Value of asset |
Maturity date if any |
Comment on assets |
| Bank accounts |
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| Savings accounts |
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| RRSP's |
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| RRSP's |
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| Term deposits |
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| Equity funds |
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| Savings bonds |
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| Furniture |
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| Auto (yr/make/Model) |
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| Auto (yr/make/Model) |
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| Consultant Phone Number |
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E-mail address |
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| Please add any comments in the NOTES section. (An incomplete questionnaire cannot be processed!) |
| How did you hear about us? |
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Notes: |
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| Financial Equalization Questionnaire Copyright 2008 by Charles S. Bell I. All rights reserved. |
