CONFIDENTIALITY PLEDGE: The information on this page will be used ONLY to generate the Reverse Mortgage Report we send you. We will not give your name, address, phone number, or ANY of the information on this page to ANYONE.

Owner #1:

Date-of-Birth:

Owner #2:

Date-of-Birth:

Address:

City:

State:

Zip Code:

County:

Telephone:

Home Value:

Total $ Mortgage(s):
If free & clear, write "none"

E-Mail:

Choices
  • What kind of cash are you looking for?
      Lump Sum
      Line-of-Credit
      Monthly Income
      Combination



Reason for
considering a
Reverse Mortgage:
If other than
Homeowner,
who to contact:

Thank you

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Countrywide Bank, FSB and Countrywide Home Loans, a Division of Countrywide Bank, FSB are Equal Housing Lenders. © 2008 Countrywide Financial Corporation. Trade/service marks are the property of Countrywide Financial Corporation and/or its subsidiaries. Countrywide Home Loans, Inc. is headquartered at 4500 Park Granada, Calabasas, CA 91302. Arizona Mortgage Banker License Number BK8805; Licensed by the Department of Corporations under the California Residential Mortgage Lending Act; Georgia Reg. #5929; Illinois Residential Mortgage Licensee; Massachusetts Mortgage Lender License No. ML 1623; this is not an offer to enter into an interest rate lock-in agreement under Minnesota law; Licensed by the New Hampshire Banking Department; New Jersey (818) 313-6526, Licensed Mortgage Banker, NJ Department of Banking and Insurance; Licensed Mortgage Banker, NYS Banking Department; Registered with the Pennsylvania Banking Department; Rhode Island Lender’s License. Some products may not be available in all states. This is not a commitment to lend. Restrictions apply. All rights reserved.