Intermediary
mortgage data
capture form
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* Halifax do not accept applications where the customer benefits from diplomatic immunity.
Number of applicants
Is this a remortgage? Yes No
Do you require a KFI from Halifax? Yes No
Level of service for this application Level of service – execution only rationale
Advised Execution only
Fee 1
Fee 2
Fee 3
Intermediary fees
Fee type Amount of fee
How much of the fee is refundable?
£ £ £ £ When payable On cancellation On completion On cancellation On completion On application Within 14 days completion On cancellation On completion £ £ Separated Separated Married/Civil
partnership Single Married/Civil partnership Single
Widowed Divorced/Dissolved Civil partnership Widowed Divorced/Dissolved Civil partnership
Marital status
Has your name ever changed? Yes No Yes No
Gender Male Female Male Female
Date of birth
Previous first name Previous middle name Previous surname
How many dependent children do you have?
Nationality Dual Nationality Country of residence
Do you have diplomatic immunity?* Yes No Yes No
Forename 1 – as shown on id
Forename 2 – as shown on id (if applicable) Forename 3 – as shown on id (if applicable) Surname
Personal details
Title Mr/Mrs/Miss/Ms/Dr/Other
Work telephone number Home telephone number Mobile number
Work Home Mobile Work Home Mobile
Preferred contact number
Work email address Home email address
Applicant 1
Applicant 2
On application Within 14 days completion On application Within 14 days completion High net worthRejected advice
Mortgage professional Non-interactive sale
Special needs Large print Braille Audio text Large print Braille Audio text
Has your address changed in the last 3 years?
Current address
Date moved into current address
Will the existing mortgage be repaid
within one month of completion? Yes No Yes No
Customer type
Existing Halifax
Borrower Home Mover
Remortgage First time buyer
Remortgage – own conveyancer
Existing Halifax
Borrower Home Mover
Remortgage First time buyer
Remortgage – own conveyancer
Customer information
Residential status Home owner – mortgage Renting Home owner (mortgage free)
Family/Friend
Home owner – mortgage Renting Home owner (mortgage free)
Family/Friend
Applicant 1
Applicant 2
Date moved into previous address Date moved out of previous address Residential status
Home owner (mortgage free) Family/Friend
Home owner (mortgage free) Family/Friend
Residential status
Date moved into previous address Date moved out of previous address First previous address in last 3 years
Postcode Postcode
Second previous address in last 3 years
Postcode Postcode
Postcode Postcode
Yes No Yes No
Personal details (continued)
Applicant 1
Applicant 2
Home owner – mortgage Renting Home owner – mortgage Renting
Home owner – mortgage Renting Home owner (mortgage free)
Family/Friend
Home owner – mortgage Renting Home owner (mortgage free)
3 Was the verification taken? Face to face Non Face to face Face to face Non Face to face
Money laundering
Type of secondary verification provided Type of standard verification provided Document reference
Issuing office/organisation
Applicant identification
Applicant 1
Applicant 2
Date of issue
Document reference
Issuing office/organisation Date of issue
Employment details
Applicant 1
Applicant 2
Type of anticipated retirement annual income
£ £
Anticipated retirement annual income Frequency of anticipated retirement annual income
Type of anticipated retirement annual income
£ £
Anticipated retirement annual income Frequency of anticipated retirement annual income
Start date of employment
What type of occupation are you in?
e.g. Sales, office, professional, trades
Percentage of business owned % %
Anticipated age of retirement Contract type
Employment type
Permanent Probationary
Piecework Sub-contract
Seasonal/Temp Fixed/short term Agency
PAYE Self employed
Permanent Probationary
Piecework Sub-contract
Seasonal/Temp Fixed/short term Agency
PAYE Self employed
Number of jobs per applicant
(If ‘Yes’, please complete the ‘Other Income’ section on page 5.) Do you have income from any
other sources? Yes No Yes No
Name of employer/business
Postcode Employer’s/business address
Postcode Employer’s/business telephone number
Income
£ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £Gross basic salary Annual commission Annual bonus Annual overtime
If self-employed
Can income
be verified? Can income be verified?
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Latest year Previous year 2nd previous year Projected year Year end date Turnover (£) Gross profit (£) Net profit (£) Assets (£) Liabilities (£)
Year end date Turnover (£) Gross profit (£) Net profit (£) Assets (£) Liabilities (£)
Year end date Turnover (£) Gross profit (£) Net profit (£) Assets (£) Liabilities (£)
Year end date Turnover (£) Gross profit (£) Net profit (£) Assets (£) Liabilities (£)
5 What year did you acquire an interest in
the business?
In what year was the business established?
Does the business have
accounts? Yes No Yes No
Name of accountant’s firm Accountant’s address
Postcode
Postcode
Postcode
Postcode Accountant’s telephone number
Name of previous employer/business Previous employer’s/business address
Previous employer’s/business telephone number
Previous employer’s/business fax number What type of employment was this?
e.g. Sales, office, professional, trades
(If total employment history is still less than 18 months, please complete section 2 on page 12.) Start date of employment
End date of employment
£ £
Other income
What type of income is this? Annual amount (£)
£ £
What type of income is this? Annual amount (£)
Applicant 1
Applicant 2
Monthly interest payments £ What equity stake will be held by the
customer? %
Shared equity
Monthly rental commitments £ What percentage share will be
purchased? %
Shared ownership
Name of shared ownership company
Scheme(s) required
Right to buy Second home loan Shared equitySource of deposit Builder/Seller Concessionary Equity Gift
Homebuy Housing Assoc or RSL Loan Savings
Tenants Incentive Scheme None
£ Purchase price/valuation
£ Market value (right to buy)
£ Cost of improvements
Loan details
Total value of outstanding mortgages with Lloyds Banking Group
£ Total value of cash incentives
£
Product details
Provide breakdown of the mortgage required. Parts 2 and 3 are where multiple products,terms or repayment types are required.
Product code (if known) Type of product e.g. fixed, tracker
Interest rate charged Product term/end date Loan amount Loan term (years) Repayment type Purpose
Existing Halifax mortgage account number (if porting)
Part 1
£
What is your preferred payment date?
Part 2
£
Part 3
£
Is product fee to be paid up front? Yes No Yes No Yes No
Maturity date for each repayment vehicle Interest only amount
Give details of new or existing plans or policies to be used with the interest only part of this mortgage.
Endowments Stocks & Shares ISA
Unit Trusts/ Open Ended Investment Companies
(UK) Investment Bonds Stocks & Shares Pensions
Sale of other residential property – Please also complete Interest only – Other residential property form for each property. Total
Monthly premium Reference/Account number £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ £ Loan amount
7
Credit commitments
(these include Switch/Visa Debit card, Visa/ MasterCard, Annex/Diners card, store cards, other cards, current accounts, bank loans, other loans, savings accounts, school fees, child care, student loans and second home running costs)
Type of commitment
Whose name is commitment in?
Name of lender/company
For mortgage commitments only, complete the information below:
£ £ £ £ £ £ £ £ £ £ £ £ £ £
Commitment 1 Commitment 2 Commitment 3 Commitment 4 Commitment 5
Yes No Yes No Yes No Yes No Yes No
Monthly repayment Balance outstanding End date of loan
Number of months in arrears
Will this be repaid on completion in full? If yes, source of funds to repay Total monthly maintenance payments
Mortgage type Remaining term Repayment type Name of lender/company Monthly repayment Balance outstanding End date of loan Current months in arrears Intend to repay on completion Source of repayment
Second home monthly running costs
Yes No
Yes No
Have any future known changes to income/ expenditure been taken into account?
If you have additional mortgage commitments complete section 3 on page 12.
Personal finances
(both applicants)
Time with bank
Applicant 1
Applicant 2
Years Years
Property information
Postal address of the property
Postcode
Property
What type of property is this?
Detachment type Detached Semi detached End terrace
House Bungalow Converted flat Purpose built flat
Mid terrace Other
If the property is a flat, number of floors in the block
Which floor is the flat on? No of bedrooms
If a new property is being purchased, please confirm the building standards indemnity scheme
NHBC Zurich Municipal Consultant Monitored
Premier Guarantee/
Liberty Legal Building Lifeplans/ Allianz Global Risks CRL LABC New Homes
Warranty LABC Hallmark Warranty Buildzone
Other None
Who is selling the property?
Normal Local Authority New Town Corporation
Builder/
developer Halifax selling as possessor Housing Assoc. The Coal Authority
Investment Club Name
Builder’s name Year property built
Yes No
Was the property built in the last 12 months?
Purchase type Normal Sitting tenant Inheritance Gift Other Local authority
Yes No
Property to be occupied for the first time in its current state?
Yes No
Do you currently live at the property?
Yes No
Do you currently own the property? Has any applicant been in arrears in the last six years with any borrowing or ever had a property repossessed?
Yes No
Has any applicant had a County Court Judgement (CCJ) or default registered against them or, if self employed, against their business within the last 6 years?
Yes No
Has any applicant been declared bankrupt, entered into an IVA or debt relief order within the last six years or still have an outstanding bankruptcy restriction order?
Yes No
9 How much will the following be?
(if applicable)
£
Annual ground rent
£
Annual service charge
£
Annual chief rent or feu duty (Scotland)
Remaining term of lease (if leasehold) Leasehold
Freehold
Ownership Interest Common hold
What is the tenure of the property?
Legal title
Entry date – Scotland only
New build Refurbishment Conversion
Type of initial occupancy property
Has your home or nearby building been damaged by subsidence, heave, landslip or does it show any signs of cracking or bulging of walls?
Yes No
Remortgage details
(only to be completed for
remortgage applications)
Lender’s name
Mortgage account number
Outstanding mortgage amount £ Please provide details of any
improvements you have made to the property (including estimated costs)
Original purchase price £
Yes No
Off road parking
Yes No No. of
acres
A garden
Yes No
Road charge liability
Yes No
Is there any other secured lending on the property?
Remortgage only Remortgage & home improvements
How many cars can be garaged?
Remortgage & debt consolidation Other Remortgage home improvements & debt consolidation
Does the property have:
A conservatory Yes No
Central heating type Gas Electricity Oil Solid fuel Other
Central heating Full Part None
Accommodation
Please provide the following details about the property
Number of bedrooms Number of bathrooms Number of separate toilets Number of living rooms Number of habitable rooms
Other secured lending
Loan 1
Loan 2
Loan 3
Account number Name of lender
Repaid Postponed Repaid Postponed Repaid Postponed
To be repaid or postponed
Yes No Yes No Yes No
Customer advised if deed of postponement or ranking agreement needed
Forename(s) Surname Forename(s) Surname
Other occupants
Please give the names of anybody aged seventeen or over and not party to the mortgagewho will live at the property.
Valuation details
Valuation Survey and Valuation Building Survey and Valuation
Remortgage Property Assessment Remortgage Valuation
(Applies where product selected offers free valuation incentive)
Access to the property The keys can be obtained from:
Other contact details Selling agent (if different)
Selling agent’s telephone number Extension
Telephone number Evening telephone number Name
Conveyancer’s details
Who is acting for you? Name of firm Address Telephone number Fax number Postcode Yes No
Are you using your own conveyancer? Valuation type
11 Would you like a Halifax home insurance
quote? Quote No Quote
Insurance requirements
The property must be insured. We will contact you with details of our general insurance products and provide no obligation quotes, unless insurance has already been arranged.Buildings Contents
Has insurance already been arranged?
Yes Yes No No Company Company
Supporting information
If you want to provide any additional information to support your application, please use the section below.Section 1 Additional information on previous addresses
Section 2 Additional information on current/previous employers
Section 3 Additional information on mortgage commitments Mortgage type
Remaining term Repayment type Mortgage lender Monthly running cost Monthly payment Outstanding balance End date
Current months in arrears Intend to repay on completion Source of repayment
£ £ £
13 Section 4 Any other information
you feel we might need to know to help us assess your application for a mortgage, in particular, if the loan extends beyond retirement age. Please confirm how you intend to maintain payments.
Easy ways to make your payments
For your convenience monthly payments will be made from a bank/building society using direct debit. Please complete the section below. Payment mandate
Instructions to your bank or building society to pay direct debits
To: The Manager
Bank or Building Society Address
Postcode
Please pay Halifax Direct Debits from the account detailed on this Instruction subject to the safeguards assured by The Direct Debit Guarantee.
I understand that this instruction may remain with Halifax and, if so, details will be passed electronically to my Bank/Building Society.
Name of account holder(s) Bank or Building Society account number Branch sort code
Halifax plc reference number
Signature(s) Date
Banks and Building Societies may not accept Direct Debit Instructions for some types of accounts.
Do you want to pay your insurance premiums in monthly instalments? Yes No
Please retain this section for your information
The Direct Debit Guarantee – this should be retained
• This Guarantee is offered by all Banks and Building Societies that take part in the Direct Debit Scheme.
The efficiency and security of the scheme is monitored and protected by your own Bank or Building Society.
• If the amounts to be paid or the payment dates change, the Halifax will notify you 4 working days in advance of your
account being debited or as otherwise agreed.
• If an error is made by Halifax, a division of Bank of Scotland plc, or your Bank or Building Society, you are guaranteed
Originator’s Identification Number 8 8 3 0 0 8
15
THIS PAGE SHOULD BE READ AND RETAINED BY ALL CUSTOMERS
Customer confirmation
If I apply for a mortgage I confirm that I make the following statements:
I declare that:- 1. I apply for a loan on the security of the property described in this application; 2. I believe the information given in this application is correct.
I authorise you to:- 3. Make any enquiries of any third parties for reference purposes and for the third party to disclose any information to you;
4. Change the address on all my accounts held with members of your group of companies. I agree that:- 5. You and any subsidiary or associated company of yours, will retain commission paid or
allowed on any insurance you arrange;
6. You may be provided, by the policy or plan provider, with any information relating to any life policy or investment plan being taken into consideration by you in connection with this mortgage;
7. I will notify you of any changes in circumstances relating to my purchase or mortgage before it is entered into and I authorise my conveyancer to disclose such information to you;
8. Relevant data may be passed to any guarantor of my loan or to their legal adviser; 9. Where I am making this application with one other joint applicant (but not more
than one other), following completion you may act on the request of either of us for a payment arrangement, payment holiday or the release of any retained funds or drawdown of reserve/credit available under the mortgage. I also agree that such a request may be made in person, in writing, by telephone or online.
10. If I borrow and do not repay in full and on time, you may tell credit reference agencies who will record the outstanding debt and my details may be submitted to the Council of Mortgage Lenders possessions register;
11. I have received information explaining property assessments.
I understand that:- 12. The payment of any fees is non-refundable and shall not mean that you have to make an advance;
13. If I/we choose a Homebuyers Survey and Valuation Report, you will choose the valuer for the property assessment and that it is the valuer’s responsibility to agree the Conditions of Engagement for the private survey element with me;
14. When considering an application for credit, you may use the information supplied to you to offer additional products.
Data protection notice Your information will be held by Bank of Scotland which trades as Halifax, part of the Lloyds Banking Group.
More information on the Lloyds Banking Group can be found at www.lloydsbankinggroup.com.
Your personal information will be shared within the Lloyds Banking Group so that we and any other companies in our Group can look after your relationship with us. By sharing this information it enables us to better understand your needs, run your accounts, and provide products in the efficient way that you expect.
We will share your personal information from your application with fraud prevention agencies. If false or inaccurate information is provided and fraud is identified, details of this fraud will be passed to these agencies to prevent fraud and money laundering. Further details explaining how information held by the fraud prevention agencies may be used can be obtained by reading the privacy notice at www.halifax.co.uk or contacting your local branch.
We may obtain information about you from credit reference agencies, fraud prevention agencies, and Group records to check your credit status and identity. The agencies will record our enquiries which may be seen by other companies who make their own credit enquiries. This may affect your ability to obtain credit elsewhere in the near future. We may also use credit scoring.
Your application will be assessed using credit reference agency records relating to you and anyone with whom you have a joint account or similar financial association. If this is a joint application and such a link does not already exist then one may be created now. These links will remain until you successfully apply for a “notice of disassociation” at the credit reference agencies.
If you are providing information on behalf of a joint applicant, by continuing with this application you confirm that you have their permission to do so and they have agreed that we are authorised to search, link and record information about them at credit reference agencies.
Remortgage customer
authority
(where applicable)
1. I authorise you or any conveyancers acting for you in connection with the proposed remortgage of my property:
• to obtain the title deeds to the property;
• to obtain a repayment figure from my/our current lender(s).
2. I confirm that I will make my own enquiries about and pay any fees or charges made by my current lender in connection with the repayment of my existing mortgage (including any administration fees made in respect of sending the title deeds to your conveyancer and providing a repayment figure and any fees in connection with my existing mortgage). 3. I understand that your conveyancer is only representing you and that if I want
independent legal advice at any stage of this transaction I will obtain and get it myself. 4. I understand that you may not arrange for an inspection of the property to be carried out.
I further understand that you will not routinely tell me what your assessment of the value of the property is.
I understand that, if you are prepared to make me a loan, I must not rely upon any assessment made as an indication of the value of the property. You have informed me and I accept that, if I require any information about the value or condition of the property or about any health and safety issues, it is my responsibility to obtain independent advice before I go ahead with the remortgage of the property.
I authorise your conveyancer to obtain copies of any document held at any of the land registries in England and Wales, Scotland and Northern Ireland.
We may ask you to provide physical forms of identity verification when you open your account. Alternatively, we may search credit reference agency files in assessing your application. The agency also gives us other details and information from the Electoral Register to verify your identity. The agency keeps a record of our search, whether or not your application proceeds. Our search is not seen or used by lenders to assess your ability to obtain credit.
Under the Data Protection Act you have the right of access to your personal data. The Act allows us to charge a fee of £10 for this service. If anything is inaccurate or incorrect, please let us know and we will correct it.
Lloyds Banking Group companies may use your information to contact you by mail, telephone, email or text message about products and services that may be of interest to you. If you do not wish to receive this information please contact your local branch or visit www.halifax.co.uk for details of how to opt out of this service.
It is important that you understand how the personal information you give us will be used. Therefore, we strongly advise that you read our Privacy Statement, which you can find at www.halifax.co.uk/securityandprivacy/privacy.asp or you can ask us for a copy. By applying for a mortgage, you agree to your personal information being used in the ways we describe in our Privacy Statement. Please let us know if you have any questions about the use of your personal information.
