| Name of Person Completing this Form: |
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| E-mail of Person Completing this Form: * |
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| Phone Number of Person Completing this *Form: |
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| Sales Price * |
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| Transaction Type * |
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| Estimated Close Date * |
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| Borrower 1 Full Name: * |
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| Borrower 1 Social Security Number: |
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| Borrower 1 Current Address: |
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| Borrower(s) Marital Status: |
|
-If Checked' Please provide death certificate |
| Borrower 2 Full Name: |
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| Borrower 2 Social Security Number: |
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| Borrower 2 Current Address: |
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| Borrower(s) Title Agent Contact Information, if applicable: |
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| Property Address 1: * |
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| Property Address 2:* |
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| City: * |
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| State: * |
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| Zip Code: * |
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| County: * |
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| City inspection required? |
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| Is there a HOME OWNERS ASSOCIATION? If yes, please provide contact information or status letter: |
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| Selling(s) Full Name: |
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| Selling(s) Current Address If different from property address: |
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| Selling(s) Marital Status: |
|
-If Checked' Please provide death certificate |
| Selling Concessions (Cash): |
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| Selling(s) Title Agent Contact Information, if applicable: |
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| Purchaser(s) Mortgage Company: |
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| Loan Officer Name: |
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| Loan Officer Phone Number: |
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| Loan Officer Email: |
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| Loan Amount(s): |
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| Type of Mortgage: |
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| Lender(s) Information (Include Mortgage Clause, CPL, Addressee): |
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| Is recent survey available? |
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| Mortgage Payoff Information, if any: |
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| Creditor Payoff Information, if any: |
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| Please attach the PA, if available: |
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| Additional files for this transaction: |
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| Additional files for this transaction: |
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| Selling Broker (Company): |
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| Selling Broker Address: |
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| Selling Broker Agent: |
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| Selling Broker Phone: |
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| Selling Broker % Commission: |
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| Selling Broker Email: |
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| Selling Broker Compliance/Transaction Fees: |
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| Listing Broker (Company): |
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| Listing Broker Phone: |
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| Listing Broker % Commission: |
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| Listing Broker Compliance/Transaction Fees: |
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