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Revised date: 11/9/17
Demographic Information of Borrower
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 fullled. 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. 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. Instructions: You may select one or more “Hispanic or Latino” origins and one or more designations for “Race.” If you do not wish to provide some or all of this information, select the
applicable check box.
q I do not wish to provide this information q I do not wish to provide this information
Ethnicity
q Hispanic > q Mexican q Puerto Rican q Cuban
q Other Hispanic or Latino >
Enter origin
Examples: Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran,
Spaniard, etc.
q Not Hispanic or Latino
q I do not wish to provide this information
Ethnicity
q Hispanic > q Mexican q Puerto Rican q Cuban
q Other Hispanic or Latino >
Enter origin
Examples: Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran,
Spaniard, etc.
q Not Hispanic or Latino
q I do not wish to provide this information
Race
q American Indian or Alaska Native
Name of enrolled or principal tribe:
q Asian
q Asian Indian q Chinese q Filipino q Japanese
q Korean q Vietnamese
q Other Asian—Enter race
Examples: Hmong, Laotian, Thai, Pakistani, Cambodian, etc.
q Black or African American
q Native Hawaiian or other Pacic Islander
q Native Hawaiian q Guamanian or Chamorro q Samoan
q Other Pacic Islander—Enter race
Examples: Fijian, Tongan, etc.
q White
q I do not wish to provide this information
Race
q American Indian or Alaska Native
Name of enrolled or principal tribe:
q Asian
q Asian Indian q Chinese q Filipino q Japanese
q Korean q Vietnamese
q Other Asian—Enter race
Examples: Hmong, Laotian, Thai, Pakistani, Cambodian, etc.
q Black or African American
q Native Hawaiian or other Pacic Islander
q Native Hawaiian q Guamanian or Chamorro q Samoan
q Other Pacic Islander—Enter race
Examples: Fijian, Tongan, etc.
q White
q I do not wish to provide this information
Sex
q Male q Female q I do not wish to provide this information
Sex
q Male q Female q I do not wish to provide this information
To be completed by nancial institution (for application taken in person)
Was the ethnicity of the Borrower collected on the basis of visual observation or surname?
q Y q N
Was the sex of the Borrower collected on the basis of visual observation or surname?
q Y q N
Was the race of the Borrower collected on the basis of visual observation or surname?
q Y q N
Was the ethnicity of the Borrower collected on the basis of visual observation or surname?
q Y q N
Was the sex of the Borrower collected on the basis of visual observation or surname?
q Y q N
Was the race of the Borrower collected on the basis of visual observation or surname?
q Y q N
The demographic information was provided through:
q Phone q Fax or mail q Email
q Face-to-face (includes electronic media with video component)
The demographic information was provided through:
q Phone q Fax or mail q Email
q Face-to-face (includes electronic media with video component)
Loan originator information
Loan organization name
Address
Loan originator organization NMLSR ID State license ID#
Loan originator name
Loan originator NMLSR ID# State license ID#
Email Phone
Applicant name(s)
14164 Donner Avenue, Truckee, Ca 96161