Referring Broker Information

(If no broker is involved, proceed to the next page.)

Broker Company Name:

Broker Contact:

BRE License #

Broker Phone:

NMLS ID #:

Street Address

City

State

Zip Code

Email Address

IMPORTANT: Read these instructions before completing this application.

Applicants should complete this form (including the referenced addenda) as “Borrower” or “Co-Borrower,” as applicable. Co-Borrower information must also be provided (and the appropriate box checked) when the income or assets of a person other than the Borrower (including the Borrower’s spouse) will be used as a basis for loan qualification or the income or assets of the Borrower’s spouse or other person who has community property rights pursuant to state law will not be used as a basis for loan qualification, but his or her liabilities must be considered because the spouse or other person has community property rights pursuant to applicable law and Borrower resides in a community property state, the security property is located in a community property state, or the Borrower is relying on other property located in a community property state as a basis for repayment of the loan.

Private Capital Investments requires that you certify your application by submitting an electronic signature. To certify your application, read the text below and provide an electronic signature by typing your name. Original wet signatures will be required at a later time. I certify that all the information in the application is accurate and true.

If this is an application for joint credit, Borrower and Co-Borrower each agree that we intend to apply for joint credit (sign below):

Borrower Signature (Type in Name):

Co-Borrower Signature (Type in Name):

*Respond Required