Submit this form on-line, or print it, complete it, and fax it to (973) 473-3638.

Applicant's Name
Applicant's Address
Apt. No. or P.O. Box
Street Address
City   State   Zip
Telephone No.
Fax No.
Property Address
Street Address
City   State   Zip
Nearest Cross Street
Type and Mortgage Term
Mortgage Amount $
Property Description
Type of Property
Type of Contruction
No. of stories Age of Building
Square Footage Lot Size
Financial Details
Purchase Price/ Estimated Value $ Present Owner
Monthly Rent Income $ Other income from property $
Lease or month-to-month? If lease, gross or net?
Estimated or Actual Monthly Expenses:
Real Estate Taxes $ Hazard Insurance $
Heat/Fuel $ Utilities $
Maintenance $ Management $
Reserve for Replacement $ TOTAL $
Notes
Fill out any other information you think would be helpful in evaluating this loan request.
Environmental Checklist
Please check yes or no as applicable to the property that will secure the mortgage for which you are applying.
1. Yes   No	Has the site been previously used for commercial or industrial purposes?
2. Yes   No	Are there areas where green plants refuse to grow?
3. Yes   No	Are there or have there been underground storage tanks on the site?
4. Yes   No	Is there a landfill on the property?
5. Yes   No	Has the property ever been used for waste disposal treatment or storage?
6. Yes   No	Are there any distinctive chemical odors at the site?
7. Yes   No	Are there any signs of stains or seepage on the site?
8. Yes   No	Is there any existing chemical contamination of the property, inside or outside the building?
9. Yes   No	If there are any underground storage tanks on the property, are they or have they been used for storage of petroleum products?
10. Yes   No	Is the facility in compliance with all applicable environmental laws and regulations?
11. Yes   No	Is the Industrial Sites Recovery Act (ISRA) applicable to this site?
12. Yes No	Are there any specially controlled substances (e.g., asbestos, PCBs) which may be on site?
13. Yes   No	Is the site or the operations under any enforcement activity?
14. Yes   No	Is asbestos used to insulate any of the pipes or heating apparatus in the building?
Submit this form on-line, or print it, complete it, and fax it to (973) 473-3638. You will be contacted within 1 business day.