Information Verification, Background,

and Credit Card Authorization

I hereby authorize Agyrtis, LLC to verify my statements regarding my current

employment, income, expenses, assets and liabilities and any other information that is

required to process my mortgage loan application. I further authorize Agyrtis, LLC to order a consumer credit report and background check, to verify any other required

information, and to charge me a fee for this credit report. It is understood that a copy of this form also serves as authorization.

The information that Agyrtis, LLC obtains will only be used in the processing of

this application.

I authorize Agyrtis, LLC to charge my credit card $100.00 for a single borrower

and $150.00 for a co-borrower to generate a tri-merge credit report. I understand this is not a commitment to lend, and that this credit report fee is non-refundable.

Borrower Name:_________________________________________________________

Borrower Address:_______________________________________________________

Social Security Number:__________________________________________________

Brorrower Drivers License:_________________________ State___________________

Co-Borrower Name:______________________________________________________

Co-Borrower Address:____________________________________________________

C0_Bosswer Drivers License________________________ State__________________

Social Security Number:__________________________________________________

Cardholder Name:_______________________________________________________

Phone Number:_________________________________________________________

Email:_________________________________________________________________

Billing Address:_________________________________________________________

City: ______________________________St: ____________Zip:__________________

MasterCard ☐ Visa ☐ Discover ☐

Credit Card Number _____________________________________________________

Expiration date:_______________________ Card Security Code__________________

Borrower Signature __________________________________Date________________

Co-Borrower Signature _______________________________Date________________