CIRCLE ONE:     REFINANCE            PURCHASE              HOME EQUITY        PROPERTY CONSTRUCTION

                                   RELOCATION               DRIVE-BY

DATE: ____________________

CLIENT NAME _____________________________________________________________________________________

CLIENT ADDRESS ___________________________________________________________________________________

CITY ______________________________________ STATE _____________ ZIP_________________________________

PHONE ( )_____________________

FAX ( ) _______________________

EMAIL ADDRESS ___________________________________________________________________________________

PLEASE SEND THE COMPLETED REPORT VIA: ___EMAIL (.PDF FILE)   ____REGULAR MAIL

PROPERTY ADDRESS ________________________________________________________________________________

CITY __________________________________________ STATE _____________ ZIP____________________________

COUNTY _________________________________________________ TOWNSHIP ______________________________

OWNER/CONTACT __________________________________________________________________________________

PHONE ( )______________________________________________  ALT. PHONE ( ) __________________________

PROPERTY INFORMATION:

AGE _________  NUMBER OF STORIES __________

GARAGE (YES) (NO) NUMBER OF BEDROOMS________

TYPE: (SINGLE FAMILY)  (MULTI-FAMILY)  (CONDO) (OTHER)

LOAN AMOUNT $_____________________ SELLING PRICE $________________________

CLOSING DATE _______________________

BORROWER/CLIENT _________________________________________________________________________________

PHONE ( )____________________________________________ALT. PHONE ( ) ______________________________