Genesis Reverse Mortgages Application (Long Form)Genesis Reverse Mortgages, Mortgage Broker Licence # 10295Step 1 of 333%Name of Primary Applicant First Middle Last Date of Birth MM slash DD slash YYYY Social Insurance Number (SIN)Marital StatusName of Co-applicant (spouse/partner) First Middle Last Date of Birth MM slash DD slash YYYY Social Insurance Number (SIN)Address of Property Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone Number of Primary ContactEmail Address of Primary Contact Existing Mortgage Details (IF Applicable) First mortgage held by:Mortgage NumberMortgage BalanceAnnual Property TaxesCurrent Value of Property (estimate)Do you have additional mortgages registered on your property? Yes No Dwelling Type Detached Semi-Detached Townhouse Townhouse (Condo) Duplex Highrise Condominium Dwelling Style One-Storey Two-Storey Three-Storey Split-Level Back-Split Property Square Footage (including basement)Property Lot Size (square feet)Garage Yes NoGarage Attached Yes NoTotal No. Bedrooms 1 2 3 4 or moreNo. of Bathrooms 1 1.5 2 2.5 3 +Please provide any additional information you would like to shareBy sending this application, I hereby authorize Genesis Associates Ltd. (aka Ontario Reverse Mortgage) to collect personal information from the individuals listed in this application for our Reverse Mortgage financing and to release the required/requested information to any institutional lenders who may be interested in providing Reverse Mortgage financing. Genesis Associates Ltd (aka Ontario Reverse Mortgage) may provide my personal information to their solicitors or appraisers with my/our consent, but only as needed for the provision of the products and services needed. At any time I may wish to discuss or revise this Privacy agreement, to which I will contact Genesis Associates Ltd. directly at 416 410.4740. Genesis Associates Ltd: FSRAO Brokerage Licence # 10295I have read and agree with the above... Yes I DO agree No I do NOT agreePhoneThis field is for validation purposes and should be left unchanged.