Name / Requested By * Phone * FAX * E-mail *   Processor Name Phone Fax Email I do not have a Processor   Loan Officer Phone Fax Email --------------- Property Information --------------- Property Address * Property City * Property State * - - Choose One - - Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Property Zip Code Property Tax Parcel ID# --------------- Borrower Information --------------- Borrower First Name * Borrower Last Name * Social Security # Work Phone Home Phone Cell FAX --------------- Borrower 2 Information --------------- Borrower 2 First Name Borrower 2 Last Name Social Security # Work Phone Home Phone Cell Fax --------------- Loan Information --------------- Loan Amount Loan ID # Lender Name/Mortgagee Lender Address Lender Phone Lender FAX Loan Type Purchase Home Equity Line Refinance Check all that apply Title Insurance/Title Policy Survey/Plot Plan/Affidavit Other (Please Specify:) --------------- Seller Information --------------- Seller Last Name Seller First Name Social Security # Phone FAX Cell --------------- Seller 2 Information --------------- Seller 2 Last Name Seller 2 First Name Social Security # Phone FAX Cell --------------- Estimated Closing Date --------------- Estimated Closing Date --------------- Special Instructions / Comments ---------------