Name*          Phone*

Email Address         Street Address*

City*         State*             Zip Code*

Number of Bedrooms        Number of Baths      Square Footage

Size of Lot:

Mortgage Information

1st Mortgage

Balance*   Payment*  Mortgage Holder 

2nd Mortgage

Balance   Payment    Mortgage Holder

Is there an Equity Line of Credit on your Home?  Yes No

If Yes..............

Balance   Payment       Holder

Total You Owe

Total Payment

How much is your home worth?

Are your payments current? Yes No

If No, please tell us how many payments you are behind and the amount you are behind.

1st Mortgage     Number of Payments Behind    $ Amount

2nd Mortgage    Number of Payments Behind    $ Amount

Credit Line        Number of Payments Behind     $ Amount

Please tell us about any Foreclosure Warming Letters or Notice of Foreclosure Letters your have received.  Tell us when you received them and if a Foreclosure sale date has been set.

Is the house in need of any repairs? Yes No

If Yes, please describe.