PO Box 9118
Michigan City, Indiana 46361
Phone: (800) 830-9788
Fax: (800)964-2076

PREQUALIFICATION AUTHORIZATION FORM

BORROWER

CO-BORROWER

__________________________________________
____________________________________________

Complete Legal Name
Complete Legal Name

__________________________________________
____________________________________________

Social Security Number
Age
Social Security Number
Age

__________________________________________
____________________________________________

Address                            City/State       Zip
Address                            City/State       Zip

_________________________________________
____________________________________________

Home Phone
Work Phone
Home Phone
Work Phone

Self Employed   (Please Circle)    Yes    No
Self Employed   (Please Circle)    Yes    No

_________________________________________
____________________________________________

Employer Position / Title Employer Position / Title

Years on Job ______
Years in line of Work _____
Years on Job _____
Years in line of Work _____

Gross Monthly Income   ____________________
Gross Monthly Income   _______________________

Other Income   ____________________________
Other Income   _______________________________

Source of Income   ________________________
Source of Income   ___________________________

_______________________________________________________________________

ASSETS

Funds on deposit (savings, checking,money market) $ ___________________________

Own Land    ______ Yes    ______ No    Value $______________      Pay Off $______________

_______________________________________________________________________

LIABILITIES

Creditor Payment Balance

Mortgages: ________________ ______________ ______________

Auto: ________________ ______________ ______________

St. Loan: ________________ ______________ ______________

Installments: ________________ ______________ ______________

________________ ______________ ______________

Revolving: ________________ ______________ ______________

Other: ________________ ______________ ______________

**Additional assets and liabilities (including alimony or child support) should be listed on a seperate sheet of paper and included with this sheet.

AUTHORIZATION TO RELEASE INFORMATION SHEET

I/We are requesting that Landmark Home & Land Company and any of it's lenders completes a pre-qualification to determine if I/we qualify for a loan. I/we authorize the recipient of this authorization to release any and all information pertaining to my credit history, income, bank, money market and similar account balances to Landmark Home & Land Company and any of it's lenders for the above stated purpose. A copy of this authorization may be as an orginal.

________________________________________________ ________________________________________________

Borrower's Signature Date Co-Borrower's Signature Date

You may print this form and Fax it to (800) 964-2076


ASSETS

Funds on deposit (savings, checking,money market)	$ ___________________________
Own Land ______ Yes ______ No Value $______________ Pay Off $______________
_______________________________________________________________________



LIABILITIES

	Creditor	Payment	Balance
Mortgages:	________________	______________	______________
Auto:	________________	______________	______________
St. Loan:	________________	______________	______________
Installments:	________________	______________	______________
	________________	______________	______________
Revolving:	________________	______________	______________
Other:	________________	______________	______________
**Additional assets and liabilities (including alimony or child support) should be listed on a seperate sheet of paper and included with this sheet.


AUTHORIZATION TO RELEASE INFORMATION SHEET
I/We are requesting that Landmark Home & Land Company and any of it's lenders completes a pre-qualification to determine if I/we qualify for a loan. I/we authorize the recipient of this authorization to release any and all information pertaining to my credit history, income, bank, money market and similar account balances to Landmark Home & Land Company and any of it's lenders for the above stated purpose. A copy of this authorization may be as an orginal.