Hudson Valley Professional Center

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Linda Jean Sampson
Registered Mortgage Broker New York State Banking Department
4 Crestview Avenue Cortlandt Manor, New York 10566
Phone: (914) 737-8830 Fax: (914) 737-6805

RELEASE OF INFORMATION

The individual whose information is entered below hereby grants to Linda Jean Sampson, Mortgage Broker full authorization to obtain all information regarding his or her employment, bank accounts and credit history, including real estate loans, whether open or closed. Linda Jean Sampson, Mortgage Broker is also authorized to request, from a company of its choice, a full credit report on the previous and present credit of the undersigned. This authorization is valid for a period of one hundred and twenty days (120) from the date below. A photocopy of this release may be used to obtain any or all of the information stated above.

Name
Street Address
Street Address line 2
City
State
Zip Code
Social Security Number
Email Address
Driver's License Info	State License number Exp. Date
Date of Birth
Today's Date
I hereby certify that I am the person listed above and I further certify that the above information is all true and accurate. (CHECK BOX)	Yes No
NOTICE REQUIRED BY LAW	Linda Jean Sampson, Mortgage Broker will be requesiing credit information on you from third parties, including a credit report, in connection with your loan application, It you ask, Linda Jean Sampson, Mortgage Broker will .tell you the name and address of the consumer reporting agency that furnished the credit report. If your loan is renewed, extended or updated, Linda Jean Sampson Mortgage Broker may request additional consumer reports without notifying you

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