GENERAL INFORMATION
I am the:
Note Holder
Real Estate Broker
Attorney
Accountant/CPA
Mortgage Broker
Bank Officer
Note Broker
Other
Financial Advisor

Your Name (not your client’s name)
*Your Company Name:
*Your Address:
*Your City:
*Your State:
*Your Zip:
*Your Phone #:
Your Fax #:
*Your E-Mail Address:

YOUR CLIENT'S DATA
Your Client’s Name:
(For your protection)
Your Client’s Address:
Your Client’s City:
Your Client’s State:
Your Client’s Zip:
Your Client’s Phone #:
Your Client’s Fax #:
Your Client’s E-Mail Address:

NOTE SERVICING AGENT
Servicing Entity Name
Address:
City:
State:
Zip:
Contact Name:
Contact Phone #:

CLOSING INFORMATION
Creator of Note (Name)
Attorney Name:
Address:
City:
State:
Zip:
Phone #:
Fax #:

Escrow Company Name
Escrow #:
Address:
City:
State:
Zip:
Phone #:
Fax #:

Title Insurance Company
Title Agent Name:
Address:
City:
State:
Zip:
Phone #:
Fax #:

If Note Assigned
Assignee Name:
Address:
City:
State:
Zip:
Phone #:
Fax #:

NOTE PAYER INFORMATION
*Payer’s Name
*Current Address
*City
*State
*Zip
*Phone
Fax
E-Mail

Prior Address:
City
State
Zip

Social Security #
Payer’s FICO Score

CO-Payer’s Name:
Current Address:
City:
State:
Zip:
Phone:
Fax:
E-mail Address:

Prior Address:
City
State
Zip

*Social Security #
CO-Payer’s FICO Score

PROPERTY INFORMATION
*Property Address Unit #
*City
*State
*Zip
*County
*Current Value
*How was the value determined?
Appraisal
Realtor
Tax Assessment
Other

Date of Appraisal

COLLATERAL TYPE:
(Please choose either residential, commercial or land)

RESIDENTIAL:
Single Family Residence
Condo
Mobile Home (Single wide) w/land
Mobile Home (Double wide) w/land
If Mobile Home, What Year was it Manufactured?

Description of Neighborhood:

Is Property Owner Occupied or Rental? Owner Occupied Rental
If rented: Amount of Rental Income $
Property Size: Lot Size or # of acres

COMMERCIAL (with improvements)
Description of Business or Number of Apartments

Amount of Lease/Rental Income $

Property Size: Lot Size or # of Acres

LAND
Description:
Unimproved Land
Improved Land
Commercial Land
Buildable Lot
Farm Land
Timber Land

Property Size: Lot size or # of Acres

NOTE INFORMATION
Note: New Note Existing Note (over 6 months)
Position of Note: First Position Second Position Other
Date of Property Sale:
Property Sales Price:
Cash Down:
Amount Financed 1st Position
Amount Financed 2nd Position
Amount Financed Total
Are there any Liens on Property? Yes No
If Yes, $ Amount of Liens
Current 1st Position Note Balance
Current Liens or Other Note Balance
Current Total Debt/Loan Balance
Current Value of Secured Property
Total Loan to Value % (Total Loans divided by Property Value)
This Note Loan to value % (This Note Balance Divided by Property
Value)

Original Note Balance
Months Amortized
Payment Amount $
Interest Rate

Payments Made
Monthly
Quarterly
Semi Annual
Annually

First Payment Due Date
# Payments Made
Final Payment Date
# Payments Remaining
Next Payment Due Date
Payment Status current delinquent
If Applicable:
Balloon Due Date:
Balloon Amount:

I have the following and can make copies available by:
Email Fax Mail

Original Real Estate Note yes no
Closing Statement yes no
Recent Appraisal yes no
Proof of Insurance yes no
Recent Photo of Property yes no
Payer’s Credit Report yes no
CO-Payer’s Credit Report yes no

Comments or added details about note: