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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
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	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: Why we need to know	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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