Form 115B – Fill Out and Use This PDF

Palm Harbor Homes

America’s Choice

15303 Dallas Parkway, Ste. 800

Palm Harbor Village

Factory Clearance Outlet

Addison, TX 75001

Country Place Homes

Masterpiece Homes

(972) 991-2422

Austin Quality Homes

Energy Efficient Housing

INVESTIGATOR

PARTIAL DOWN PAYMENT AMOUNT

D.P. SOURCE

DEALER #

$

(A)

APPLICANT INFORMATION

(B)

CO-APPLICANT INFORMATION

FULL NAME - Last, First, Middle

FULL NAME - Last, First, Middle

Other names used including Maiden name:

Other names used including Maiden name:

BIRTHDATE

DEPENDENT CHILDREN

BIRTHDATE

DEPENDENT CHILDREN NOT LISTED UNDER (A) APPLICANT

NUMBER:

AGES:

NUMBER:

AGES:

SOCIAL SECURITY NO.

MARITAL

M=Married

S=Separated

SOCIAL SECURITY NO.

MARITAL

M=Married

S=Separated

STATUS:

U=Unmarried (single, divorced, widowed)

STATUS:

U=Unmarried (single, divorced, widowed)

PRESENT STREET ADDRESS

PRESENT STREET ADDRESS

CITY, STATE, ZIP CODE

CITY, STATE, ZIP CODE

HOW LONG AT

HOME PHONE NO.

HOW LONG AT

HOME PHONE NO.

PRESENT ADDRESS

Years

Months

PRESENT ADDRESS

Years

Months

RESIDENTIAL

H=Home Owner

R=Renter

MO. RENT OR

RESIDENTIAL

H=Home Owner

R=Renter

MO. RENT OR

STATUS:

P=Parents

O=Other

MTG. PYMT.$

STATUS:

P=Parents

O=Other

MTG. PYMT.$

LANDLORD OR MORTGAGE HOLDER’S NAME

PHONE NO.

LANDLORD OR MORTGAGE HOLDER’S NAME

PHONE NO.

BALANCE OF

ACCOUNT NO.

BALANCE OF

ACCOUNT NO.

MORTGAGE: $

MORTGAGE: $

PREVIOUS ADDRESS (If less than 3 years at present address)

HOW LONG

PREVIOUS ADDRESS (If less than 3 years at present address)

HOW LONG

Years

Months

Years

Months

OTHER PREVIOUS ADDRESS

PREVIOUS RESIDENCE

OTHER PREVIOUS ADDRESS

PREVIOUS RESIDENCE

STATUS:

STATUS:

Applicant’s Employment

Co-Applicant’s Employment

EMPLOYER’S NAME

EMPLOYER’S CITY, STATE

EMPLOYER’S NAME

EMPLOYER’S CITY, STATE

EMPLOYER’S BUSINESS

SUPERVISOR

EMPLOYER’S BUSINESS

SUPERVISOR

SALARY (Gross)

H=Hour

W=Week

WORK PHONE NO.

SALARY (Gross)

H=Hour

W=Week

WORK PHONE NO.

$

PER

M=Month

Y=Year

$

PER

M=Month

Y=Year

JOB TITLE OR OCCUPATION

JOB CODE

HIRE DATE

JOB TITLE OR OCCUPATION

JOB CODE

HIRE DATE

PREVIOUS EMPLOYER

EMPLOYED

PREVIOUS EMPLOYER

EMPLOYED

FROM

TO

FROM

TO

PREVIOUS EMPLOYER’S ADDRESS

PHONE NO.

PREVIOUS EMPLOYER’S ADDRESS

PHONE NO.

OTHER INCOME NOTE: Alimony, child support, or separate maintenance incomes do not have to be revealed unless the applicant wishes to have such sources considered as a

basis for repayment of the requested credit.

(A) SOURCE OF OTHER INCOME

MONTHLY AMOUNT

(B) SOURCE OF OTHER INCOME

MONTHLY AMOUNT

CHILD CARE

MONTHLY AMOUNT

$

$

$

CHECKING ACCOUNT WITH (Name and address)

PHONE NO.

ACCOUNT NO.

SAVINGS ACCOUNT WITH (Name and address)

PHONE NO.

ACCOUNT NO.

LAST VEHICLE FINANCED

DATE PURCHASED

MODEL, YEAR, AND MAKE OF VEHICLE

# VEHICLES OWNED

ADDRESS

PHONE NO.

CURRENT BALANCE ($)

MONTHLY PAYMENT ($)

AMOUNT PAST DUE ($)

OWNER

CREDITOR NAME, ADDRESS AND PHONE NUMBER

FHA INSURED?

DATE OPEN

HIGH CREDIT

ACCOUNT NUMBER

CURRENT BAL. ($)

MO. PAYMENT ($)

AMT. PAST DUE ($)

VISA

CURRENT BALANCE

MONTHLY PAYMENT

MASTERCARD

CURRENT BALANCE

MONTHLY PAYMENT

DEPARTMENT STORE

CURRENT BALANCE

MONTHLY PAYMENT

CURRENT BALANCE

MONTHLY PAYMENT

___ Yes

___ No $

$

___ Yes ___ No

$

$

___ Yes ___ No

$

$

Other

$

$

RELATIVE LIVING NEAREST APPLICANT (Name and address)

RELATIONSHIP

RELATIVE’S PHONE NO.

RELATIVE LIVING NEAREST APPLICANT (Name and address)

RELATIONSHIP

RELATIVE’S PHONE NO.

ONLY APPLICABLE TO MANUFACTURED HOMES. Do the undersigned intend to occupy the property as their primary residence?

.......................................................................................................

Y = Yes

N = No _______

❑ I do not wish to furnish this information

❑ I do not wish to furnish this information

❑ No Co-Applicant

Applicant:

Co-Applicant:

ETHNICITY:

❑ Hispanic or Latino

❑ Not Hispanic or Latino

ETHNICITY: ❑

Hispanic or Latino

❑ Not Hispanic or Latino

RACE:

❑ American Indian or Alaskan Native

❑ Asian ❑Black or African American

RACE:

❑ American Indian or Alaskan Native

❑ Asian ❑Black or African American

❑ Native Hawaiian or Other Pacific Islander

❑White

❑ Native Hawaiian or Other Pacific Islander

❑White

SEX:

❑ Male ❑ Female

SEX:

❑ Male

❑ Female

If the answer is “yes” to any of the following questions, explain on the attached sheet - Enter Y(yes) or N(no) in both columns

APPLICANT

CO-APPLICANT

(1) HAVE YOU DECLARED BANKRUPTCY WITHIN THE PAST 10 YEARS?

WHERE?

WHEN?

(4) ARE YOU A CO-MAKER OR GUARANTOR ON A NOTE? FOR WHOM?

HOW MUCH?

(5) HAVE YOU ANY OTHER APPLICATION FOR AN FHA TITLE 1 IMPROVEMENT LOAN PENDING AT THIS TIME?

regarding their credit experience with you to any and all credit reporting agencies.

APPLICANT

CO-APPLICANT

SIGNATURE

SIGNATURE

REQUIRED X ________________________________________________ DATE ________________

REQUIRED X ________________________________________________ DATE ________________

(A) APPLICANT Driver’s License No. ____________________________________________________

(B) CO-APPLICANT Driver’s License No. ____________________________________________

Make

Model:

Yr:

Width:

Length:

New_______

Used_______

Primary Residence

Land or Lot Payment

Yes_______

No_______

$_____________

Physical Address

MH PLACEMENT

❑ Leased Land

❑ Indian Reservation

❑ Park

❑ Owned Land Free & Clear

❑ Owned-Lien

❑ Family Land

Conventional_____

Land/Home_____

Land-in-lieu_____ FHA_____ VA_____

FINANCING OPTIONS

Constrcution_____

90 Day No Pay_____

Term:

Rate:

Payments:

______ MTH

_____%

PARTICIPATION

FLOOR PLAN

As Earned______

Up Front______

Pre Sold______

Stock______

Points

#______________

Finance:____________________

Cash:_________