The purpose of collecting this information is to help ensure that all applicants are treated fairly and that the housing needs of communities and neighborhoods are
being fulfilled. For residential mortgage lending, Federal law requires that we ask applicants for their demographic information (ethnicity, sex, and race) in order to
monitor our compliance with equal credit opportunity, fair housing, and home mortgage disclosure laws. You are not required to provide this information, but are
encouraged to do so. You may select one or more designations for “Ethnicity” and one or more designation for “Race.” The law provides that we may not
discriminate on the basis of this information, or on whether you choose to provide it. However, if you choose not to provide the information and you have made this
application in person, Federal regulations require us to note your ethnicity, sex, and race on the basis of visual observation or surname. The law also provides that
we may not discriminate on the basis of age or marital status information you provide in this application. If you do not wish to provide some or all of this
information, please check below.
I (“Borrower”) certify and represent to lender (“Originator”) as follows:
I hereby declare that I have no intention of making the property (subject property listed in my loan application) my principal residence.
Additionally, I declare that I have no intention of utilizing the property as a second home and/or any surviving spouse or family member shall live in the
property. I understand that this loan is a business purpose loan and not a household purpose loan. The loan proceeds are intended to be used and
shall be used for business purpose only, not for personal use.
I represent that I understand the difference between consumer loan for personal purposes and a commercial loan for business purposes. I represent
that this loan is not a consumer loan and therefore is not subject to any laws relating to consumer loans under any state or federal laws such as Truth
in Lending Act (15 U.S.C. § 1601 et seq.), Real Estate Settlement Procedures Act (12 U.S.C. § 2601 et seq.), Gramm‐Leach Bliley Act (15
U.S.C. §§ 6802–6809), Secure and Fair Enforcement Mortgage Licensing Act (12 U.S.C. § 5101 et seq.), and Homeowners Protection Act (12 U.S.C.
§ 4901 et seq.).
I realize the lender, broker, assignees and successors rely upon this information. I confirm I have read and understand this document. I declare under
penalty of perjury the foregoing is true and correct.
By signing this form, I/we hereby authorize lender to conduct a background and/or credit check. Additionally, the undersigned and each party to this
loan, authorizes lender to disclose to any third party, employee, agent or assignee thereof information regarding background and credit experience.
I understand that it is a federal crime punishable by fine or imprisonment, or both, to knowingly make any false statements when applying for this
mortgage, as applicable under the provisions of title 18, united states code, 1014. I also understand that the lender intends to use the data obtained
through the investigation for due diligence purposes only, and shall not disclose such information to any other party.
Entity / Company Name (if applicable)
Borrower / Authorized Signer Name (print)
Signature (Borrower / Authorized Signer)
Co-Borrower / Authorized Signer Name (print)
Signature (Co-Borrower / Authorized Signer)