A. Order Information:   Required Field *
1. Your Name: *
2. Company Name: *
3. Email Address: *
4. Contact #: *
5. FAX #: *
B. Property Information:
1. Street Address: *
2. City: *
3. State: * ZIP Code: *
4. County:
5. Parcel ID #:
6. Full Legal Description:
C. Buyer / Borrower Information:
1. Name of Borrower: * SSN #: *
2. Name of Co-Borrower: SSN #: *
3. Marital Status: *
4. Borrower's Address: *
5. City: *
6. State: * ZIP Code: *
7. Borrower's Contact #: *
8. Occupancy Status: *
9. Buyer's REALTOR¨ Name: Contact #: *
10. Escrow Deposit Held By: Amount: *
D. Loan / Lender Information:
1. Purpose of This Loan: *
2. Purchase Price:
3. Loan Amount: *
4. Name of Proposed Lender: *
5. Loan Officer's Name: Contact #: *
6. Estimated Closing Date:
E. Seller Information:   Leave this Section Blank if this is a Refinance Transaction
1. Name of Seller: SSN #: *
2. Name of Co-Seller: SSN #: *
3. Marital Status:
4. Seller's Address:
5. City:
6. State: ZIP Code: *
7. Seller's Contact #:
8. Seller's REALTOR¨ Name: Contact #: *
F. Additional Information:
1. First Mortgage Holder: Loan #: *
2. Name of Contact: Contact #: *
3. Second Mortgage Holder: Loan #: *
4. Name of Contact: Contact #: *
5. Does a Survey need to be ordered for the Property? YES NO
6. Does a Termite Inspection need to be ordered? YES NO
7. Is there a Homeowner's and/or Condo Association? YES NO
8. If YES, Name of Contact: Contact #: *
9. Hazard Insurance Company:
10. Name of Contact: Contact #: *
11. Additional Comments:


Please also FAX the following Items, if available, to our office at (302) 765-9601:
Copy of prior Title Insurance Policy, Copy of prior Survey (If Refinance), Original Termite Inspection (If Applicable), and a Copy of the Purchase and Sale Contract (If Purchase and Sale Loan).

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