Date: _______________
Borrower(s): ________________________________________
Application Number: ________________________________________
Subject Property Address: ________________________________________________________________________
________________________________________________________________________
RESPA – Certification of Receipt of GFE and Borrower Intent to Proceed
Date of Initial GFE: _____________ Date Initial GFE was provided: _____________
Complete the following based on the initial GFE
Charges):
Amount in Block A (Your Adjusted Origination Charges) $_____________
our Services):
Amount in Block B (Your Charges for All Other Settlement Services $_____________
Charges):
Amount in Block A+B (Total Estimated Settlement Charges) $_____________
Borrower and Broker Certification
By signing below, the Borrower and Broker certifies the following:
• The information provided above matches the initial GFE.
• The borrower(s) has/have been provided with an initial GFE and written Settlement Se ervice Provider list within
three business days of the application date.
• The borrower(s) has/have received the initial GFE
• The borrower(s) has/have expressed their intention to proceed with the loan the initial GFE was issued for.
• The Borrower(s) was/were not charged any fee other than a reasonable credit report fee, if charged, prior to
their receipt of the initial GFE.
___________________________________ __________________________________
Borrower Date Borrower Date
___________________________________ __________________________________
Borrower Date Borrower Date
__________________________________ _________________________________
Mortgage Broker Company Name Signature Date
_________________________________
Printed Name
RESPA – Certification of Receipt of GFE and Borrower Intent to Proceed 360 Mortgage Group, LLC
st
Effective January 1 , 2010 Page 1 of 1