21st Mortgage Corp.

620 Market Street, Suite 100 Knoxville, TN 37902

Online Application Available at: 21stmortgage.com

Office Number: 1-800-955-0021 Fax Number: 1-877-370-2100

NMLS2280

APPLICANT CREDIT INFORMATION: If this is an INDIVIDUAL application, complete section A. If this is a JOINT application, complete section A&B. NOTE: if married, the spouse is not required to be the joint applicant. Please advise whether credit references and/or credit history should be investigated under another name. It is a crime to intentionally falsify information on this application.

Date: Retailer/Broker #:
Property will be: Purpose of the Loan: Loan Type:

Seller: Phone:
Primary Residence Purchase Chattel Buy For Refinance Secondary Investment

Sales Person/Rep: James Robinson City: State: Estimated Loan Amount: $

Construction Construction Permanent

Land Home Land in Lieu

Physical Address where home will be located: City: Site of Placement: State:
Owned Property with no lien Leased

Zip:

COUNTY:

Owned Property Land Contract/Mortgage Trust Deed

Family Land Community Reservation Information on the Land Lease Community, Land Owner name, Tribe if home is to be placed on a Reservation, or the mortgage holder: Name: Phone Number: Monthly Site Payment $

(A) APPLICANT
FULL NAME - Last, First, Middle Birth Date: Sex: (Optional) Male # Dependents: Social Security #: Marital Status: Married Ages: Birth Date: Sex: (Optional) Male # Dependents:

(B) CO-APPLICANT
FULL NAME - Last, First, Middle Social Security #: Marital Status: Married Unmarried Ages:

Female

Unmarried

Separated

Female

Separated

APPLICANT'S RESIDENCE
Current Street Address (5 Years Residence Required, attach supplement if needed) City, State, Zip: Mailing Address (if different from physical)
How long at present address? Homeowner *

CO-APPLICANT'S RESIDENCE
Current Street Address (5 Years Residence Required, attach supplement if needed) City, State, Zip: Mailing Address (if different from physical)
Mo. Mrtg/Rent: How long at present address? Homeowner *

County: Home Phone:

County: Home Phone:

Yrs

Mo Renter

Yrs

Mo Renter

Name of Mortgage Holder or Landlord: Telephone number: *I intend to (circle one) Sell, trade, rent, other - explain. Email Address: Previous address (if current address is less than 5years) City, State, Zip: Name of Mortgage Holder or Landlord: Telephone number: Name of nearest Relative NOT living with you: Relationship: Phone: How long?

Name of Mortgage Holder or Landlord: Telephone number: *I intend to (circle one) Sell, trade, rent, other - explain. Email Address: Previous address (if current address is less than 5years) City, State, Zip: Name of Mortgage Holder or Landlord: Telephone number: Name of nearest Relative NOT living with you: Relationship: Phone: How long?

NMLS2280 Page 1 of 3

APPLICANT'S EMPLOYMENT (Min. 3 year history)

CO-APPLICANT'S EMPLOYMENT (Min. 3 year history)

Yes / No

Please attach supplement for additional employment history if necessary

Please attach supplement for additional employment history if necessary

APPLICANT'S OTHER INCOME

CO-APPLICANT'S OTHER INCOME

Income from SSI, retirement, disability, alimony, child support or separate maintenance agreement need not be disclosed if you do not wish to have it considered as a basis for undertaking or repaying
How Long: How Long: Monthly Amt: $ Monthly Amt: $ How Long: How Long: Monthly Amt: $ Monthly Amt: $

ASSET INFORMATION
Applicant Bank Name: Co-Applicant Bank Name: Retirement/401K with: Auto #1: Yr/Make Auto #2: Yr/Make Auto #3: Yr/Make Other Real Estate Owned Alimony/Maintenance: Child Support: Garnishment: Value: $ Value: $ Value: $ Value: $ City, St City, St City, St Lender: Lender: Lender: Lender:
Account type: Account type: Account type:

Balance: Balance: Balance: Balance: Balance: Balance: Balance:

$ $ $ $ $ $ $

Payment: $ Payment: $ Payment: $ Payment: $

(A) APPLICANT
YES /NO YES /NO YES /NO Monthly pmt $ Monthly pmt $ Monthly pmt $ Alimony/Maintenance: Child Support: Garnishment:

(B) CO-APPLICANT
YES /NO YES /NO YES /NO Monthly pmt $ Monthly pmt $ Monthly pmt $

If the answer is yes to any of the questions (1-5), explain on attached sheet. Enter Y (yes) or N (no) for Borrower and/or Co-Borrower

QUESTIONS Are you a U.S. Citizen? Are you a permanent resident alien?
Have you declared bankruptcy within the last 10 years? If yes, when did you file? Have you had any judgments, repossessions, garnishments, or other legal proceedings filed against you in the past 7 years? Do you have any past due obligations to or insured by any agency of the Federal Government? Are you a co-maker or guarantor on a note? If yes, for whom? How Much? Do you have any other applications for an FHA Title 1 improvement loan(s) pending?

Borrower Yes Yes Yes Date: Yes Yes Yes Yes No No No No No No No

Co-Borrower Yes Yes Yes Date: Yes Yes Yes Yes No No No No No No No

NMLS2280 Page 2 of 3

The following information is requested by the Federal Government for certain types of loans related to a dwelling in order to monitor the lender's compliance with the equal credit opportunity fair houssing and home mortgage disclosure laws. You are not required to furnish this information, but are encouraged to do so. The law provides that a lender may discriminate neither on the basis of this information nor on whether you choose to furnish it. If you furnish the information, please provide both ethnicity and race. For race you may check more than one designation. If you do not furnish ethnicity, race or sex, under Federal regulations this lender is required to note the information on the basis of visual observation or surnamne, I f you do not wish to furnish the information, please check the box below. (Lender must review the above material to assure that the disclosures satisfy all requirements to which the Lender is subject under applicable state law for the particular type of loan applied for.)

I decline to furnish this information BORROWER: Ethnicity: Hispanic or Latino Not Hispanic or Latino Race: American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

I decline to furnish this information CO-BORROWER: Ethnicity: Hispanic or Latino Not Hispanic or Latino Race: American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

Sex:

Male

Female

Sex:

Male

Female

Additional Disclosures California: An applicant, if married, may apply for a separate account. It is illegal to discriminate in the provision of availability of financial assistance for the purpose of the purchase, construction, rehabilitation of any one to four unit family residences occupied by the owner and for the purpose of the house improvement of any one to four unit family residence by considering: 1. Trends, characteristics or conditions in the neighborhood or geographic area surrounding a housing accommodation, unless the financial institution can demonstrate in the particular case that such consideration is required to avoid an unsafe and unsound business practice; or 2. Race, color, religion, sex, marital status, national origin or ancestry. It is illegal to consider the racial, ethnic, religious or national origin composition of a neighborhood or geographic area surrounding a housing accomodation or whether or not such composition is undergoing change, or is expected to undergo change, in appraising a housing accomodation or in determining whether or not, or under what terms and conditions, to provide financial assistance. If you have questions about your rights, or if you wish to file a complaint, contact 21st Mortgage Corporation or the California Department of Corporations at: 320 West 4th St, Ste 750, Los Angeles, CA 90013, or 1390 Market St, Ste 810 San Francisco, CA 94102 New York and Vermont: In connection with your application for credit, a consumer report may be requested in connection with such application. Upon request, you will be informed whether a consumer report was requested, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. If your application is granted, subsequent consumer reports may be requested or utilized in connection with any updates, renewal or extension of the credit for which application was made or for any other legitimate purpose associated with the account. Ohio: The Ohio laws against discrimination requires that all creditors make credit equally available to all creditworthy customers and that credit reporting maintain separate credit histories on each individual upon request. The Ohio Civil Rights Commission administers compliance with this law. Wisconsin: No provision of a marital property agreement, a unilateral statement under Wisc. Stat. 766.59 or a court decree under Wisc. Stat. 766.70 adversly affects the interest of the creditor unless the creditor, prior to the time the credit is granted, is furnished a copy of the agreement, statement, or decree of has actual knowledge of the adverse provision when the obligation to the creditor is incurred. NON-APPLICANT SPOUSE WAIVER OF NOTICE: I agree to waive notice of any extension of credit in connection with this application: Non-applicant Spouse: Date Additional disclosures may be required for the following states: Texas, New York, Ohio, Oregon. These documents are separate from this application and must be submitted with the application for 21st Mortgage Corp. to process your request. Each of the undersigned specifically represents to Lender and to Lender's actual or potential agents, brokers, processors, attorneys, insurers, servicers, successors and assigns and agrees and acknowledges that: (1) the information provided in this application is true and correct as of the date set forth opposite my signature and that any intentional or negligent misrepresentation of the information contained in the application may result in civil liability, including monetary damages, to any person who may suffer any loss due to reliance upon any misrepresentation that I have made on this application, and/or in criminal penalties including, but not limited to, fine or imprisonment or both under the provision of Title 18, United States Code, Sec. 1001, et seq.; (2) the loan requested pursuant to the application (the "Loan") will be secured by a mortgage of deed of trust on the porperty described herein; (3) the property will not be used for any illegal or prohibited purpose or use; (4) all statements made in the application are made for the purpose of obtaining a residential mortgage loan; (5) the property will be occupied as indicated herein; (6) any owner or servicer of the Loan may verify or reverify any information contained in the application from any source named in the application, and Lender, its successors or assigins may retain the original and/or elecronic record of the application, even if the Loan in not approved; (7) the Lenders and its agents, brokers, insurers, servicers, successors, and assigns may continuously rely on the information contained in the application, and I am obligated to amend and/or supplement the information provided in the application if any of the material facts that I have represented herein should change prior to the closing of the Loan; (8) in the event my payments on the Loan become delinquent, the owner or servicer of the Loan may, in addition to any other rights and remedies that it may have relating to such delinquency, report my name and account information to one or more consumer credit reporting agencies; (9) ownership of the Loan and/or administration of the Loan account may be transferred with such notice as may be required by law; (10) neither Lender nor its agents, brokers, insureres, servicers, successors, or assigns has made any representation or warranty, expressed or implied, to me regarding the property or the condition or value of the property; and (11) my transmission of the application as an "electronic recored" conaining my "electronic signature" as those terms are defined in applicable federal and/or state laws (excluding audio and video recordings), or my facsimile transmission of the application containing a facsimile of my signature, shall be as effective, enforceable and valid as if a paper version of the application were delivered containing my original signature. I give permission to Lender to investigate my credit and employment history and authorize my employer, landlord, depository institution, and credit company to release information about me. I acknowledge that my dealer is neither a broker nor a credit grantor. This application may be considered withdrawn if I do not inquire about its status within 30 days of the date of this notice.

Borrower Signature

Date

Co-Borrower Signature

Date

NMLS2280 Page 3 of 3