What type of property are you considering a Reverse Mortgage for? *

If Other, please exlplain

Applicant First Name *

Applicant Last Name *

Applicant Phone Number *

Applicant Email Address *

Applicant Age *

Applicant Gender (Lifetime Guaranteed, actuarial date required) *

Male

Female

Is there another owner of this house? (eg. Spouse/Partner) *

Yes

Secondary Applicant

Secondary Applicant Last Name

Secondary Applicant Phone Number

Secondary Applicant Email Address

Second Applicant Age

Secondary Applicant Gender (Lifetime Guaranteed, actuarial date required)

Male

Female

What do you think your credit rating is like? *

Good (Good - Excellent)

Bad (Average - Poor)

Ugly ("Bad Things Happen to Good People")

What is the Postal Code of the Property? *

What is the property Address? *

How would your property compare to other similar properties in your area? *

Better than average

Similar to others

Worse than average

If better than average, why? (Eg. Recent renovations, additions, maintained)

If worse than average, why? (Eg. Repairs needed)

What is the estimated value of your home? (Eg. $500,000, $1,000,000)

Do you have an existing Mortgage, 2nd Mortgage and/or Home Equity Line of Credit? *

Yes

What is the estimated balance(s) owing? (Eg. $25,000, $40,000)

Do you have Credit Card, Personal Loans or Lines of Credit Debts? *

Yes

What is the approximate balance owing on Credit Card, Personal Loans & Line of Credit Debts?

Do you have a Car Loan/Lease? *

Yes

What is the balance owing on you Car Loan/Lease? What is the payment size?

What is your current level of knowledge of Reverse Mortgages? *

Seen Ads but don't really understand it

Some Knowledge but have some/many questions

Researched Reverse Mortgage and know how it works

Have you downloaded and read the Canada Reverse Mortgage Guide ® ? *

Yes

Do you plan on moving in the next 3 to 5 years? *

Yes

Not sure

Do you believe your current home will meet your families' needs over the next 3 to 5 years? *

Yes

If your home will not meet your families needs over the next 3 to 5 years, please explain why!

As mortgage brokers, we want you to understand any mortgage you receive from us. We gave you the E-book called Canada Reverse Mortgage Guide ® to review and read. Will you promise to read it / read it prior to obtaining your new funding? *

Yes

As mortgage brokers, we need to be able to speak to you. You can text/write/call at anytime. Will you agree to text/write/call us with any questions so we can address them, let us explain your mortgage pre-approval and/or approved commitment issued to you? *

Yes

Do you agree to obtain the advice of your lawyer, for independent legal advice PRIOR to funding, so you may review our mortgage broker funding solution, your mortgage commitment and drafted mortgage documents? *

Yes

Do you verify that the information in this form is accurate to your best knowledge and will be considered current unless we are notified otherwise. Personal information will be held in the strictest of confidence and only released to third parties to fulfill our obligations to you or to comply with regulatory requirements or when required to do so by law?

Yes