SS Form

Contact Information

 
Name *

First
Last
 
Email *
 
Phone Number *
 

Property Information

 
Property Ownership *
 Primary Residence 
 Investment 
 
 
Address *

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
 
1st Lender Name *
 
Is this an FHA or VA Loan? *
 Yes 
 No 
 
 
If yes, Which?
 
Approximate Loan Balance on 1st *
 
2nd Lender Name - if applicable
 
Approximate Loan Balance on 2nd
 
3rd Lender Name - if applicable
 
Approximate Loan Balance on 3rd/Other Liens
 
Are 2nd or 3rd a line of Credit?
 Yes 
 No 
 
 
Other Liens/Loans
 
Do you have a Foreclosure Sale Date? *
 Yes 
 No 
 
 
If yes, what date?

MM		 /
DD		 /
YYYY
 
Date last mortgage payment was made *

MM		 /
DD		 /
YYYY
 
Do you have Mortgage Insurance?
 Yes 
 No 
 
 
How did you hear about us? *
 

Questions

 
Have you recently spoken with your bank about your options? *
 Yes 
 No 
 
 
Have you spoken to another agent or real estate team in regards to a short sale? *
 Yes 
 No 
 
 
Additional Comments?
 
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