Brokers
SwapRentSM Application Form
APPLICANT INFORMATION
First Name:  Last Name:
Date of Birth:
Phone:
Social Security Number:
Home Address:
City:
ZIP Code:
Estimated Value: $
Amount Owed: $
Owned for? Yrs Mos
Previous Address:
City:
ZIP Code:
Own Rent
Monthly Payment or Rent:
How long? Yrs
EMPLOYMENT INFORMATION
Current Employer:
Employer Address:
How Long? Yrs
City:
ZIP Code:
Phone:
Email:
Fax:
Position:
Hourly Salary
Annual Income: $
Previous Employer:
Address:
How Long? Yrs
City:
ZIP Code:
Phone:
Email:
Fax:
Position:
Hourly Salary
Annual Income: $
CO-APPLICANT INFORMATION, IF FOR A JOINT ACCOUNT
First Name:  Last Name:
Date of Birth:
Phone:
Social Security Number:
Home Address:
City:
ZIP Code:
Estimated Value: $
Amount Owed: $
Owned for? Yrs Mos
Previous Address:
City:
ZIP Code:
Own Rent
Monthly Payment or Rent:
How long? Yrs
CO-APPLICANT EMPLOYMENT INFORMATION
Current Employer:
Employer Address:
How Long? Yrs
City:
ZIP Code:
Phone:
Email:
Fax:
Position:
Hourly Salary
Annual Income: $
Previous Employer:
Address:
How Long? Yrs
City:
ZIP Code:
Phone:
Email:
Fax:
Position:
Hourly Salary
Annual Income: $
HOME INFORMATION
Mortgage Holder:
Mortgage Payment: $ Taxes/Ins: Y N
Second Mortgage Holder:
Second Mortgage Payment: $
Please list the name(s) of everyone on the title of your property:
BANK ACCOUNT AND OTHER SAVINGS
Bank or Financial Institution
Account Type
Account No.
Current Balance
OTHER ASSETS OR SOURCES OF INCOME
Description
Annual Income or Value: $
DECLARATIONS
Please select "Yes" or "No" to each of the following questions.
* A=Applicant C=Co-Applicant
A
C
A. Are there any outstanding judgments against you?
B. Have you been declared bankrupt in the past 7 years?
C. Are you currently involved in, or contemplating bankruptcy proceedings?
D. Is anyone suing you?
E. Have you directly or indirectly been involved in a loan that resulted in foreclosure?
F. Are you presently delinquent or in default on any Federal debt or any other loan, mortgage, financial obligation, bond or loan guarantee?
G. Are you obligated to pay alimony, child support or separate maintenance?
H. Are you a co-maker or endorser on a note?
I. Are you a U.S. Citizen?
J. Are you a permanent resident alien?
K. Are you applying for a SwapRentSM subsidy on your primary residence?
L. Do you own other real estate?
SIGNATURES
Each of the undersigned specifically represents to REIDeX, Inc. (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 this 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.