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The information you provide on this form will remain confidential.

Tell us about you...
* Your First Name:
* Your Last Name:
* E-mail Address:
Day Time Phone: (Please include area code)
Evening Phone: (Please include area code)
Best Time To Call:
Tell us about the property...
Property street address:
Property city:
Property state:	Please selectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Property Zip:
The Property is currently:	Please selectOwner OccupiedOccupied by RenterVacant
No. of Bedrooms:	<1123455+
No. of Baths:	<1123455+
Square Footage:
Age of House:
Garage:	Please selectOne Car AttachedOne Car DetachedTwo Car AttachedTwo Car DetachedCarportNoneOther
What is the general condition of the house:	Please selectExcellentGoodFairPoorUGLY!
Please describe any needed repairs in this box:
Check all that apply
Wood Floors  Formal Dining Room   Carpeting  Game Room   Tile  Fireplace   Finished Basement  Deck   Unfinished Basement  Swimming Pool   Privacy Fence  Other Fence   Brick  Vinyl Siding   Steel Siding  Wood Siding   Other Siding  Stucco   Central Heat  Central Air   Floor Furnace  Wood Stove   Septic Tank  Crawl Space   Slab  Storage Shed   Shop
Tell us about the numbers...
How much do you feel the property is worth:
1st mortgage balance:
1st mortgage payment amount:
Does the 1st mortgage payment include taxes and insurance:	YesNo
Are there other mortgages on the property:	YesNo
What is the combined balance of all mortgages:
What is the combined monthly payment on all mortgages:
Please tell us about any other liens and/or other title problems that may affect this property by typing an explanation here:
Are all mortgage payments current: If payments are current click here	YesNo
If payments are not current, how far behind are they...
1st mortgage
$ Amount Behind:
# of payments:
2nd mortgage
$ Amount Behind:
# of payments:
Other mortgage
$ Amount Behind:
# of payments:
Have you received a foreclosure notice:	YesNo
Has a foreclosure sale date been set:	YesNoUnknown
Sale Date:	(Please click on the calendar icon to select the date)
Just a couple more questions...
Is your property currently listed with a real estate agent/broker	YesNo
If property is listed when does your listing expire:
Are you currently in bankruptcy:	YesNo
How did you hear about us:	Please selectReferral from AttorneyReferral from CPAReferral from FriendReferral from RealtorLocal NewspaperPostcardLetterInternet search engineLink from other Internet siteOther
Please provide any further comments that you feel are important in the box below:
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